The ‘‘Mini-Jupette’’ sling at the time of inﬂatable penile prosthesis implantation:

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ORIGINAL ARTICLE

The ‘‘Mini-Jupette’’ sling at the time of inﬂatable penile prosthesis implantation:

Adequate treatment for erectile

dysfunction with mild incontinence and/or climacturia after radical prostatectomy

La bandelette « Mini-Jupette » lors de l’insertion d’un implant pénien

gonﬂable : un traitement chirurgical adéquat d’une dysfonction érectile avec incontinence urinaire légère et/ou orgasmurie après prostatectomie totale

R. Andrianne

DepartmentofUrologyandSexualMedicine,CETISM(centred’étudeetdetraitement interdisciplinairedesexopathologiemasculine,orCenterforthestudyandinterdisciplinary treatmentofmalesexualhealth),UniversityHospitalCenter(CHU),SartTilman,4000Liège, Belgium

Received14May2018;accepted18May2019 Availableonline9July2019

KEYWORDS Penileprosthesis;

Post-radical prostatectomy erectiledysfunction;

Climacturia;

Urinaryincontinence;

Malesling

Summary

Aim.—The usual morbidity after radical prostatectomy(RP)implies, the possibleneedfor inﬂatable penile prosthesis (IPP). This study aims to validate the efﬁcacy and safetyof a slingcalled‘‘Mini-Jupette’’concomitantlywiththeimplantationofanIPPthatwillcounteract mildUI(<2pads/day)associatedornotwithclimacturiaforpatientsresistanttonon-invasive therapeuticapproach.

Methods.—We provideadetailed descriptionwith robustillustrationofanoriginalsurgical technique.Themethodthecriteriaanalyzed inthestudyandthestatisticalmethod.Retro- spectivedatafrom15patientsfrom2006to2016aredetailed.

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Results.—Dataabouterectilefunction,continencebeforeandafteroperationaredocumented forthiscohortwithmildincontinence(15pts—100%—meanpad/daywas1.5,SD=0.6)and climacturia(6pts-40%).Meanagewas65.9years(SD=6.3).Therewerenocomplicationsbut 2patientshaddysuriaandonepatientpresenturinaryretentionrequiringtemporarybladder drainage.At6months,incontinencewereobjectivelycuredfor80%ofpatientsand2patients (13%)improvetheircontinencebyaslightactivationoftheimplant,theclimacturiadisappeared in5patients(82%).Atelephoneinterviewshowsagooddurabilityoftheresults.withamean timeof107monthsfollow-up.

Conclusion.—Concomitantinsertionofthe‘‘Mini-Jupette’’slingduringimplantationofanIPP contributesreliably,safelyanddurablytothetreatmentofpost-radicalprostatectomymild incontinenceand/orclimacturia.

Levelofevidence.— 3.

MOTSCLÉS Implantpénien; Dysfonctionérectile post-prostatectomie; Orgasmurie;

Incontinence urinaire;

Bandelettemasculine

Résumé

But.—La dysfonctionérectile, comorbidité habituelle d’uneprostatectomie radicale (PR), implique, chez le patient motivé, lesouhait éventuel d’une prothèse pénienne gonﬂable.

L’incontinence urinaire et l’orgasmurie sont aussi des séquelles de la PR qui perturbent grandement la qualitédeviedes patients.Cetteétude validel’efﬁcacité etl’innocuitéde l’adjonction d’unebandelette synthétique sous urétrale (appelée « Mini-Jupette ») simul- tanément à l’implantation d’une prothèse pénienne gonﬂable permettant de contrer une incontinenceurinairelégère(<2protections/jour)associéeounonàuneorgasmuriepourune sériedepatientsrésistantsàuneapprochethérapeutiquenon-invasive.

Matérieletméthodes.—Nousdécrivonsetillustronsendétailunetechniquechirurgicaleorig- inale du placement d’une‘‘Mini-Jupette » sur l’urètre et suturéeaux berges internes des corporotomiesencoursd’implantationconcomitanted’uneprothèsepéniennegonﬂable.Des donnéesrétrospectivesde15patientsopérésde2006à2016sontdétaillées.

Résultats.—Lesdonnéessurlafonctionérectile,surlacontinenceavantetaprèsl’opération ontétédocumentéespourcettecohorteavecuneincontinenceurinairelégère(15pts—100%

—lamoyennedesprotections/jourétaitde1,5—DS=0,6)etuneorgasmurie(6pts-40%).L’âge moyenétaitde65,9ans(DS=6,3).Hormisdeuxpatientsprésentantunedysurieetunpatient présentantunerétentionurinairenécessitantundrainagetemporairedelavessie,lespatients n’ontpasconnudecomplicationschirurgicalesoupostopératoires.Sixmoisaprèsl’opération, lesrésultatsétaientfavorables:l’incontinenceétaitacquisepour80%despatientset2patients (13%)amélioraientleurcontinenceàl’effortparunelégèreactivationdelaprothèsepénienne; l’orgasmuriedisparaissaitchez5patients(82%).Unsuivitéléphoniqueactualisémontraitune bonnedurabilitédesrésultatsdel’interventioncombinéeavecuneduréemoyennede107mois desuivi.

Conclusion.—L’insertion concomitante d’une bandelette « Mini-Jupette » au cours de l’implantationd’uneprothèsepéniennegonflablecontribuedefaçondurable,fiableettoute sécuritéautraitementd’uneincontinencelégèreet/oud’uneclimacturieliéeàuneprostate- ctomietotale.

Niveaudepreuve.— 3.

Introduction

Followingradicalprostatectomy(RP)forlocalizedprostate cancer,erectiledysfunction(ED)mayensue,oftennecessi- tatingtheneedforsemi-rigidorinﬂatablepenileprosthesis (IPP)insertion. Other consequences of RP include urinary incontinence(UI)andclimacturia.

TheincidenceofUIisestimatedtobeashighas33%of patientswhoreportusingprotectivedevices(suchaspads, diapersandclamps)[1].Anotheroftenunderreportedcon- sequenceofRPisclimacturiaorpost-RPorgasm-associated incontinenceinrelationtosexualstimulationand/orduring orgasm.In a meta-analysisof 43 studies, climacturia was reportedby20—93%ofRPpatientsatleastafewtimesafter

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surgery[2]. All these patients reportedsigniﬁcant bother and25%reportedlosinginterestinsexualintercourse[3].

Both UI and climacturia greatly affect quality of life domainsof prostatecancer (PCa)survivorsandhave been associatedwithpoorperformanceoutcomes.

RecommendinganIPPtoapatientwithapost-RPEDisan excellentsolution,butneglectingmildincontinenceand/or climacturialeadstoasigniﬁcant riskofinsufﬁcient global satisfaction.

Since2006, we have developed a techniqueof passive andactivecompressionoftheurethraincombinationwith theimplantation of an IPP. We named this procedure the

‘‘Mini-Jupette’’.

This operation is simple with few postoperative complications. It is effective and can help overcome an often-distressingiatrogenicsituationforPCasurvivors.We firstshared ournovel datawith an oral scientific presen- tationin 2016 at the David Ralph‘‘Penile ImplantMaster class’’inLondon.Thiswasfollowedbyavideo,whichhas sincebeen publishedonline in theVideoJournal ofPros- theticUrology[4].Multi-institutionalstudiesexaminingthe efficacyofthe‘‘Mini-Jupette’’arealsounderway,thefirst ofwhichhasbeenpublished[5].

Surgical technique

The patientis placedsupine underspinal anesthesiawith slightTrendelenburgpositionandacavernousbodyapproach is performed transversely at the level of the penoscrotal junction.A4cmtransversecutaneousincisionismadeabout 2—3cm below the penoscrotal junction. This penoscrotal incisionaffordsproximalcruralcorporacavernosa(CC)and bulbo-urethral exposure. This approach was inspired by StevenWilson’sapproachforpenoscrotalAUSimplantation in2003[6]andfurtherdescribedforpenileimplantplace- mentingreatdetailin2017[7]

The bestexposure is obtained using a disposable self- retainingretractor,whichisavailablefromBostonScientiﬁc (the ‘‘SKW’’ deep scrotal retractor) or from Coloplast (‘‘Wilson’’scrotalretractor).

Thepatientiscatheterized(18Fr)toemptythebladder andtodelineate theexactpositionoftheurethra bypal- pationduringsurgery.Thepenisiselevatedoverabeaded strapwithahook.Thisallowstissuesoverlyingthecorpora tobeeasilysweptawaybybluntﬁngerdissectionandhelps avoidanyurethralinjuryorcorporalcrossover.

AfteropeningBuck’sfascia,theventralsideofthecav- ernousbodyisreleasedatthebulbo-urethralportionofthe urethra.This surgicalexposure mustbeextendedtowards theurethralbulb,reachingthepartoftheurethrawherethe corpusspongiosumisthicker.Thetunicaalbugineashouldbe clearlyvisiblewithwell-deﬁnedlateralbordersofthecorpo- realbodiesattheleveloftheinsertionovertheischio-pubic bone.

InordertoachieveampleexposureoftheproximalCC, weseparate thescrotal septumfromtheurethral attach- ment as with an AUS implantation [6]. This manoeuvre allows access to the proximal CC for placement of the

‘‘Mini-Jupette’’andthepump.Oneormorerakehookscan furtherretractthescrotuminferiorlywitharolledspongeif

Figure1. Afterdissection,theproximalcorporacavernosaand bulbarurethrashouldbeclean.Thescrotalseptumisseparedfrom theurethralattachment.

Figure 2. The external border of the cavernotomies are sus- pended.Thecorporotomies,ofalengthof3cmminimum,areclose totheinsertionofthecavernousbodiesontheischio-pubicbone.

The‘‘Mini-Jupette’’isﬁxedbytworunningsuturespositioningon theinnerbordersofthetwocavernotomies.

necessary(Fig.1).Thelateralcavernotomiesarethensus- pendedoneachsidebyasinglestaystitch.

Fora‘‘Mini-Jupette’’procedure,thecorporotomiesare not performeda few millimeterslateralfromthe urethra but,rather,1to1.5cmlaterallyfromtheurethraandclose totheinsertionofthecavernousbodiesontheischio-pubic bone(Fig.2).

The corporotomies are made with a 15-blade or elec- trocauterybilaterally.Thedistallimitofthecorporotomies must be 1cm lowerthan the beaded strapof the Wilson retractor.Initially,thecorporotomiesareshort(1.5cm)to allowequaldilationofthetwoCC,distallyandproximally.

Proximalextensionofthecavernotomiesisthenperformed toensure thatthe corportomieshave a lengthof at least 3cmforinsertionofthe‘‘Mini-Jupette’’.

Before the dilatation of the CC, the measurement of thewidthofthepolypropylenegraftofthe‘‘Mini-Jupette’’

is made between theinner borders of the cavernotomies (Fig.3)

The‘‘Mini-Jupette’’isfashionedaccordingtothemea- surement of the medial inter-corporeal distance using a polypropylene monoﬁlamentmesh.This meshshouldhave

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Figure3. Measurementofthewidthofthepolypropylenegraft ofthe‘‘Mini-Jupette’’,between theinnerbordersofthecaver- notomies.

high porosity (pores wider than 75 microns), be biocom- patible(allowingthepassageofmacrophages,fibroblasts, neovessels and collagen fibers), and non resorbable. This meshhasthe advantageofbeingeasy tocut accordingto dimensions, havingshapememory,veryhigh resistanceto sutures,andgreatflexibilitywhichallowsforoptimuminte- gration and colonization after six monthsof implantation (BiomeshCOUSINBIOTECH-France).

DistalandproximaldilatationsoftheCCareperformedin astandardmanneraccordingtothetypeofimplantchosen (12FrforColoplastdevice,13FrforBostonScientific/AMS device).The‘‘Mini-Jupette’’isfixedbytworunningsutures withmonofilamentpolyesternon-resorbable4-0(Ti-cron^◦) ontheinnerbordersofthetwocavernotomies(Fig.2)

Cylindersizingisselectedinsuchawaythatthecylinder tubingwillemergeexactlyfromtheposteriorangleofthe cavernotomieswherethe‘‘Mini-Jupette’’isinsertedmost proximally(Fig.4).

Thecylindersarethenconventionallyintroducedintothe twocavernousbodiesbypositioningtheinﬂatableposterior portionofthecylindersatthelevelofthe‘‘Mini-Jupette’’.

Weclosethecavernotomieswitharunningabsorbablesyn- theticpolyestercopolymersuture(Vicryl^◦ orPolysorb^◦)set on2/0needle5/8tohaveawatertightclosure(Fig.5).

The tension of the ‘‘Mini-Jupette’’ is set to obtain a lightcompressionofthebulbarurethrawiththe18Fblad- dercatheterinplace.Passageofﬁnescissorsbetweenthe

‘‘Mini-Jupette’’ and the urethra should be tensionless. If signiﬁcanttensionisnoted,the‘‘Mini-Jupette’’isremoved andawidergraftisused.

Inourexperience,thechoiceoftheIPPdoesnotappear toimpactoutcomes:BostonScientific/AMS700(CXorLGX) orColoplast(TitanOTR).Implantselectiondependsonthe sizeofthepenisand/orsurgeon’spreference.Thecylinders arethenfull inflatedtoassessfunctionaloutcomesandto confirmadequatecompressionoftheurethra.

ThescrotalpumpisplacedinaDartospouch.Sincethese patientshavepreviouslyundergoneaRP,itisourpreference toperformasecondsmallcounter-incisionat thelevelof theleftantero-superioriliacspinetointroducethereservoir intotheretroperitonealspace(Fig.5).

Figure4. Thecylindertubingexitsthecorporacavernosadistally towardsthescrotumattheposteriorangleofthecavernotomyat thedeepinsertionofthe‘‘Mini-jupette’’.

Closedsuctiondrainageofthescrotalsiteisprovidedfor 12to24h.Thebladdercatheterisremoved24hpostopera- tivelyandtheprosthesisispartiallydeﬂated(1/4according toErectileHardnessScore[EHS]).Allpatientsaredischarged homewithin48hoftheprocedureandpost-operativepain ismanagedwithoralmedications.Antibacterialprophylaxis witha quinolone and clindamycin is provided for 5 days.

Accordingtoourprotocol,the penileimplant isactivated twiceadayonemonth post-operativelyandforat least3 months(15mininthemorningandintheeveningwithmobi- lizationofthepenisforabetterﬁttingofthepenistothe penileimplant).

Material and methods

The ideal indication for an IPP with concomitant ‘‘Mini- Jupette’’procedureis apatientwithpost-RPED resistant to medical treatment, and with mild incontinence (<2 pads/day)and/orclimacturia,bothresistanttophysiother- apy.

Beyondappropriatepatientselectionforapenileimplant (realisticexpectation,appropriatepatientcounseling,clas- sical discussion and informed consent), the only true contraindicationforthe«Mini-Jupette’’procedureissimi- lartothatofanAUSormaleslingandissigniﬁcantpost-void residualurinevolumesecondarytobladderoutletobstruc- tion,neurogenicbladderorpost-RPbladderneckorurethral stricture.

Datawerecollectedforcasesofconcomitantplacement a‘‘Mini-Jupette’’slingandIPP,thatwereperformed from July2006throughJune2015.Collected variablesincluded age,timefromRP,erectilefunctionaspertheInternational Indexof Erectile Function score 5 (IIEF 5), severity of UI

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Figure5. Thepenileimplantisinplace,thecontrolpumpisinthescrotum.Becausethepatienthadaradicalprostatectomy,thereservoir ispositionedintheabdomenviaanotherincision.

asperpadtest,amountofclimacturia,dataoftheopera- tiveprocedure,andtreatmentoutcomesandcomplications.

Follow-up was performed at 8 and 30 days and 3 and 6 monthspostoperatively and a longerfollow-up, by phone calls,attheendof2018foralimitedcohortwasperformed.

Uroﬂowmetrywasdoneat1month.

Results

Between2006and2015,the‘‘Mini-Jupette’’procedurewas offeredtoaselectcohortof15patientswithcomplaintsof EDafterRP,aswellasamildincontinence(1—2pads/day) withorwithoutclimacturia.Allpatientswereoperatedon bythesamesurgeonandreceivedanIPPandaconcomitant

‘‘Mini-Jupette’’.

Mean post-RP time was 32 months (10—38; SD=9.8).

The average age of the operated cohort was 65.9 years (SD=6.3).Theaveragetotaldurationofthetwointerven- tionscombinedwas72min(SD=19.8).Amongtheseﬁfteen patients,15 hadpost-RPED andmild incontinence(mean 1.5pads/day)and6patientshadpost-RPclimacturiawith signiﬁcantpsychologicalbother.IPPdevicesusedwerethe AMS700LGX in4patients (26.7%),AMSCXin9(60%)and

ColoplastTitanin2patients(13,3%).Otherclinicaldataare listedinTable1

We did not experience any immediate or late postoperative complications related to the IPP or the

‘‘Mini-Jupette’’ procedure exceptfor one case of urinary retention and2casesof post-operativedysuria(20%).For these patients, a 16 Fr urinary catheter was reinserted for afew daysalongsideanti-inflammatorytreatment and totaldeflationoftheimplantwasperformed.Nosignificant dysuriaordenovourgencywasnotedinpatientsatmonths 1,3or6.

Patientswere followed at month 3 and month 6, and as needed for patients with device failure or dissatisfac- tion.At 6 months,asatisfactory improvement ofED with the IPP was noted in the entire cohort. IIEF-5 scores, as expected, also improved, from a mean of 8.9 (SD=1.2) beforesurgery to22.5 (SD=0.4)after PI insertion,repre- sentingachangeof13.6points.Onstatisticalanalysisofthe series,wenotedalowcorrelationbetweenageandIIEF-5 scoresbeforethesurgery(␳=0.28),whichalmostdoubled afterwards(␳=0.48).Therewasnocorrelationbetweenthe IIEF-5scoreandthenumberofpads/day.

At6monthsfollow-up,12patients(80%)werecompletely dry without IPPactivation and 2 patients (13%) withpar- tial device inﬂation (EHS 2/4) during signiﬁcant physical

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‘‘Mini-Jupette’’slingatthetimeofinﬂatablepenileprosthesisimplantation461

Table1 Clinical,surgicalandoutcomesof15patientswhounderwentconcomitantinﬂatablepenileprosthesisand«Mini-Jupette»insertion.

Data Pt1 Pt2 Pt3 Pt4 Pt5 Pt6 Pt7 Pt8 Pt9 Pt10 Pt11 Pt12 Pt13 Pt14 Pt15 Mean Std

Age(y),mean(SD) 63 59 52 65 68 73 68 67 58 74 73 69 71 67 61 65.9 6.3

TimefromRP(months) 28 18 33 10 35 26 33 32 28 29 36 48 38 44 43 32.1 9.8

Operatingtime(min),mean(SD) 70 55 63 80 112 80 66 45 42 90 82 78 70 50 100 72.2 19.8

IIEF-5score,mean(SD) 9 7 8 9 9 10 10 7 NA 8 8 11 10 9 10 8.9 1.2

Urinaryincontinence

Padsperday 2 1 2 1 2 3 1 1 1 2 2 1 2 1 1 1.5 0.6

Climacturia

Rare Yes

Frequent Yes Yes Yes Yes

Always Yes

Unknow* Yes Yes

IPPtype CX LGX CX CX LGX CX Titan CX CX LGX CX CX OTR CX LGX

IntraoperativeComplications None None None None None Dysuria None None Retention None None Dysuria None None None Outcomes

IIEF-5score 24 21 20 22 24 23 23 22 NA 23 22 23 23 23 23 22.5 0.4

Urinaryincontinence

0ppd Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes

Improved Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Unchanged Yes

DrywithslightlyactivationIPP Yes Yes

Climacturia

Resolved Yes Yes Yes Yes Yes

NoClimacturiadenovo Yes Yes

Unchanged Yes

IIEF-5:internationalindexoferectilefunction5items;NA:notavailable;RP:radicalprostatectomy;IPP:InﬂatablePenileProsthesis

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activityforcompletecontrolofurinaryleakage.Nopatients reportedclimacturiadenovointhegroupofpatientswith mildisolatedincontinence. Ofthe6patientswithclimac- turia,5 patients(83%) reportedcomplete resolution.Due totheir signiﬁcant ED, lack of orgasm and intercourse, 2 patientscouldnotindicatewhethertheyhadpre-operative climacturiaanddidnothaveanypostoperatively.

As per our practice routine, only patients who are highly motivated for a clinical reassessment following RP (ED, UI and climacturia), those who are dissatisﬁed or those with complications complete long-term follow- up. In 2015, a patient who had this combined surgical approach 8 years earlier developed cylinder rupture and recurrence of UI. The IPP was replaced without manipu- latingthe‘‘Mini-Jupette’’andcontinencewasimmediately restored.

Nevertheless,betweenAugustandOctober2018,phone interviewsallowedtoassesslateoutcomesin9patientswho hadachievedcompleteresolutionofEDandUI/climacturia at 6 months post-operatively. Data was not available for 2 patients and 1 patient died from other causes. The meandurationofthisfollow-upwas107months(60—149;

SD=28.01).In thissmallcohortof patients,despite being olderwithameanageof74years(63—82;SD=6.19),patient satisfactionwithIPPwashigh(IIEF-5score:22.9),therewas goodcontrolofcontinence(meanpads0.22,SD=0.42),and therewasnorecurrenceofclimacturia.

Discussion of outcomes and operating hypothesis of the ‘‘Mini-Jupette’’

The‘‘Mini-Jupette’’procedurewhichcombinesanIPPand a mini sling has excellent efﬁciency in treating ED with 6 months post-operative IIEF-5 scores improving to 22.5 (SD=0,4),representingachangeof13,6 points,similarto solitaryIPPimplantationdataintheliterature[8].Ofnote, youngerpatientsexperiencedabetterimprovementinthis score.

Clinical follow-up of UI and climacturia can be dif- ﬁcult because, often, patients’ priorities are related to improvements in sexual function. Nevertheless, concomitant ‘‘Mini-Jupette’’ placement signiﬁcantly improved patients’post-RPUIandclimacturia.

At6monthsoffollow-up, 12of15patients(80%)were completelydry without IPPactivation, due tothepassive effect of the ‘‘Mini-Jupette’’. The remaining 2 patients (13%)requiredslightdeviceinﬂation(EHS2/4)duringsignif- icantphysicalactivityforcompleteneutralizationofurinary leakage,arepresentationoftheactiveeffectofthesling.

These results compare favorably with outcomes reported withtheAUS(65.7%),andothermaleslings(48.2—64.0%), dependingonthetypeofsling[9].

Fiveof6patients(83%)reportedcompleteresolutionof climacturiaafter‘‘Mini-Jupette’’graft placement.Wedid notobserveanydenovoclimacturiaorotherorgasmicfunc- tionafterthiscombinedprocedure.Theseexcellentresults aresuperiortootherreportedinterventionsforclimacturia (elasticlooporpelvicphysiotherapy)[10,11].

Combinationsurgeryforthetreatmentofrefractorypost- RPEDandUIwitheitheramalesling(formoderateorlight

Figure6. Howthe‘‘Mini-Jupette’’works?.

UI) or AUS (for severe UI) is becoming a more and more attractive approach for urologists. It is technically feasi- ble with either a single or dual incision approach and is associatedwithgoodsatisfactionrates anddurability.Our synchronoussingleincisionapproachofaddressingtwopost- RPcomorbidities(EDandUI)performedbysimplyinsertinga syntheticmeshoflessthan12cm²representsagreatoption forsomeselectedpatients.

But, howdoes the‘‘Mini-Jupette’’ work? According to the procedure described above, when the cylinders of the implant are not inﬂated, we believe that the ‘‘Mini- Jupette’’ acts passively by aslight compressiveeffecton theurethrawithbulbo-urethralcoaptationcomparabletoa

‘‘malesling’’withlighttension;thisispossiblebecausethe

‘‘Mini-Jupette’’isattachedveryclosetothe pelvicbone.

Duringsexualintercourseandcylinderinﬂation,the‘‘Mini- Jupette’’isstretchedandactsactively.Whenthecylinders arefullinﬂated,thedistancebetweenthe2cavernotomies increases,thisallowsforatemporarystrictercompression ofthe urethrawitheffective reductionof climacturiaand urinaryleakage(Fig.6).Urodynamicandradiologicaleval- uationsshouldhelptobetterunderstanditsmechanismof action and probablyunderstand the causeof the failures observed.

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Conclusion

ED, UI and climacturia contribute signiﬁcantly to the decreasethePCasurvivorsqualityoflifescoresleadingto generaldissatisfaction,sorevalidationofpost-RPEDshould notneglectmildUIand/orclimacturia.

The ‘‘Mini-Jupette’’procedure isan easy,inexpensive, fast,safe,usefulandreliabletechniquethatcanbeconsid- eredforsubsetsofpatientswithpost-RPclimacturiaand/or mild UI at the timeof penile prosthesis implantation. As such, it is important to query our patients regarding cli- macturiaastherearemanymenwhocanbeneﬁtfromthis combinedprocedure.

Inthissmallretrospectivestudywith6monthsfollow-up of15patients andlatephoneinterviewsof 9patients,no patientwasdissatisfiedwiththecombinedprocedure and no other adjuvant treatment for UI was required. Larger patientcohorts andlongerobjectivefollow-upareneeded toconfirmthelong-term safetyandbenefitsofthis intervention. The best mesh needs to be identified but the braidedmonofilamentpolypropylenemeshseemstobevery effective and safe, asit has already been usedfor male sling surgery. In cases of failure to resolve UI and cli- macturiawiththe‘‘Mini-Jupette’’,it willbenecessary to demonstratethatothersolutionsarepossiblewithoutdimin- ishingefficiency(AUSorsling).

Acknowledgements

Andrianne’s technique for « Mini-Jupette » insertion describedhereinisadescendantoftheteachingsandmeth- odsofDr.StevenK.Wilson’sartiﬁcialurinarysphincterand penileimplantation.

We thank Drs Faysal Yaﬁ (Newport Beach,CA), Steven Wilson(LaQuinta,CA)andKoenvanRenterghem(Hasselt, LeuvenBE)fortheircollegial,friendlyandscientiﬁcsupport foranalreadypublishedinternationalpreliminarystudy.

Anatomical drawings were made by S. Philippaerts (www.spMedical-illustration.com).

Disclosure of interest

R. Andrianne is consultant for both Boston Scien- tiﬁc/AmericanMedicalSystemsandColoplastUnitedStates Patent and Trademark Ofﬁce:Jul-6-2007: Foreign License Granted Number 40636—Number of priority application:

US60/944,944.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.

1016/j.purol.2019.05.003.

References

[1]KaoTC,CruessDF,GarnerD,FoleyJ,SeayT,FriedrichsP,etal.

Multicenterpatientself-reportingquestionnaireonimpotence, incontinenceandstrictureafterradicalprostatectomy.JUrol 2000;163:858.

[2]Frey AU, Sønksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. J Sex Med 2014;11(2):374—85.

[3]GuayA,SeftelAD.Sexualforeplayincontinenceinmenwith erectile dysfunction after radical prostatectomy: a clinical observation.IntJImpotRes2008;20(2):199—201.

[4]vanRenterghemK,AndrianneR.Inﬂatablepenileimplantwith simultaneous«mini-jupette»inapatientwithEDandclimac- turia.VJPU2016;2:068.

[5]YaﬁFA, AndrianneR,AlzweriL,Brady J,ButcherM,Cheva- lier D, et al. Andrianne Mini-Jupette Graft at the Time of InﬂatablePenileProsthesisPlacementfortheManagementof Post-ProstatectomyClimacturiaand MinimalUrinaryInconti- nence.JSexMed2018;15(5):789—96.

[6]Wilson S, Delk J, 2nd, Henry GD, Siegel AL. New surgical technique for sphincter urinary control system using upper transverse scrotal incision. J Urol 2003;169(1):

261—4.

[7]GuptaNK,RingJ,TrostL,WilsonSK,KöhlerTS.Thepenoscrotal surgicalapproachforinﬂatablepenileprosthesisplacement.

TranslAndrolUrol2017;6(4):628—38.

[8]Vakalopoulos I, Kampantais S, Ioannidis S, Laskaridis L, Dimopoulos P, Toutziaris C, et al. High patient satisfac- tionafterinﬂatablepenileprosthesesimplantationcorrelates with female partner satisfaction. J Sex Med 2013;10(11):

2774—81.

[9]CrivellaroS,MorlaccoA,BodoG,Agro’EF,GozziC,PistolesiD, etal.Systematicreviewofsurgicaltreatmentofpostradical prostatectomystressurinaryincontinence.NeurourolUrodyn 2016;35(8):875—81.

[10]ChristineB,BellaAJ.Climacturia:anunder-addressedsequel ofradicalprostatectomy,buttreatmentisonlyaslingaway.J Urol2016;195:e636.

[11]Jain R, Mitchell S, Laze J, Lepor H. The effect of surgical intervention for stress urinary incontinence (UI) on post-prostatectomy UI during sexual activity. BJU Int 2012;109(8):1208—12.