Response to Comment on: The penoscrotal approach is a viable alternative to the perineal approach for artificial urinary sphincter implantation: A retrospective cohort study

Abstract

With great interest, we read the comments by Rubez et al. on our paper published in the International Journal of Impotence Research [1, 2]. Their comments are insightful and provide some interesting remarks to which we would like to comment. Our manuscript, which presents the largest contemporary series of penoscrotal implantation of an artificial urinary sphincter (AUS), aimed to demonstrate that the penoscrotal approach is safe, feasible, and effective in achieving dryness in men with stress urinary incontinence (SUI). Although we acknowledge that the retrospective, single-surgeon design may introduce performance, selection, or detection bias, we consider the study's external validity to be robust. The issues raised by the commentators regarding durability, mechanical reliability, and erosion risk were examined to the fullest extent permitted by our data. With a median follow-up of 2.3 years, we endeavoured to provide a sufficiently rigorous follow-up period to support reproducibility across centres and operators. We recognise that future prospective studies will be essential to validate and expand upon our findings. By including every consecutive patient undergoing penoscrotal AUS implanta-tion at our centre-including those with prior radiation therapy, revision procedures, or tertiary-referral status-we sought to minimise selection bias. Only patients with an inaccessible penoscrotal and thus perineal approach were excluded. Although careful consideration in the administration of antibiotics is essential, particularly given current concerns about antimicrobial stewardship, postoperative infection remains a major risk factor in prosthetic surgery. With an appropriate peri-operative antibiotic regimen, the infection rate observed in our study aligns with previously reported outcomes for penoscrotal approaches in prosthetic urological procedures [3-5]. Conversely, the utility of preoperative and postoperative oral antibiotics and prolonged IV prophylaxis has recently been proven of limited protective effect in penile prosthesis surgery [6]. Furthermore, antibacterial choices in artificial urinary sphincter surgery are partly based on expert opinion and institutional habits [7]. Yet a perioperative antibacterial and antifungal regimen is necessary to have as low an infection rate as possible. Preventive measures are justified, as infection rates in our cohort are low. Furthermore, precaution is preferable to risk; a reduction in prophylaxis might result in more infections and thus more re-interventions. Nevertheless , future prospective research may clarify what combined antimicrobial and antifungal protocols are required to achieve the lowest possible infection rates. The penoscrotal approach is often cited as one with limited proximal cuff placement in obese, post-radiation, or previously operated patients. We agree partially on this matter. Individuals who have previously undergone penoscrotal surgery may have developed scar tissue that could complicate reutilisation of the same approach. Radiated and obese patients were included in our cohort; however, we did not perform a dedicated subgroup analysis for these populations. A recent study by Dalimov et al. [8] reported no significant differences in urethral injury or infectious complications among radiated patients undergoing prosthesis implantation via a penoscrotal approach. Although challenges and higher complication rates associated with previous urethroplasty and/or irradiation in patients receiving an AUS have been described, further research is required to determine whether these rates are comparable for the penoscrotal approach [9-12]. Beyond the fact that the penoscrotal approach represents a viable and reproducible technique for AUS implantation, proficiency in both the penoscrotal and perineal approaches enables surgeons to undertake AUS placement in previously operated patients. In revision procedures, surgeons who can employ the penoscrotal approach when the original implantation was performed perine-ally are at a distinct advantage, and patients stand to benefit directly from this versatility. The mean operative time in our study was 28 minutes. As the commentators correctly note, this is largely attributable to the surgeon's level of expertise. As with all surgical procedures, a learning curve exists for the penoscrotal approach. In addition, because this technique requires dissection as proximally as possible, supervised training by an experienced proctor is essential. The influence of the operating team on procedural efficiency must also be acknowledged. Effective assistance that ensures optimal exposure, together with nursing staff who