Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists

Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists Vicktor Bruno Pereira Pinto, Jose de Bessa Jr, José Antonio Penedo Prezotti, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4993232/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in World Journal of Urology → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Urethral instrumentation (UI) in patients with an artificial urinary sphincter (AUS) demands technical considerations and poses a risk of urethral erosion, leading to serious clinical and legal consequences. We conducted a national survey to evaluate the knowledge and experience of Brazilian urologists with UI in these patients. Methods This study used an electronic survey distributed to members of the Brazilian Society of Urology. The survey included 19 multiple-choice questions assessing sociodemographic characteristics, practice patterns, AUS training, knowledge of AUS components and functionality, experience with UI in AUS patients, and interest in further training. Urologists were classified as 'competent' in AUS manipulation if they had prior experience and confidence in performing UI. Results Among 536 participants (median age 47 years [39–55]), 72.8% reported involvement in urological emergencies, with 89.9% indicating inadequate AUS training during residency. Only 29.7% had occasional or regular involvement with AUS surgeries. Of the participants, 53.4% had performed UI in men with an AUS. Prior UI had been attempted by healthcare staff in 36.2% of cases. Only 46.8% reported knowledge of AUS components and 45.1% felt competent in deactivating it. Regarding urethral catheterization, 47.2% knew the safe catheter diameter, and 20.9% identified safe catheterization duration. Overall, 45.1% self-declared competence in UI, yet many gave incorrect answers on catheter size and duration. Competence strongly correlated with knowledge of AUS components, regular implant involvement, and prior experience. Most (89.3%) expressed interest in additional training for UI. Conclusion This study highlights significant gaps in training and knowledge among Brazilian urologists regarding UI in AUS patients. These deficiencies underscore the potential for enhanced education to improve patient outcomes and reduce AUS-associated complications in Brazil and possibly broader international contexts. Artificial urinary sphincter Urinary Incontinence Male Prostatectomy Medical Education Surveys and Questionnaires Figures Figure 1 INTRODUCTION Urinary incontinence is a significant long-term complication of radical prostatectomy [1]. It has been estimated that approximately 5–10% of men who undergo this procedure experience persistent urinary incontinence, necessitating surgical intervention [2]. The artificial urinary sphincter (AUS) has been the cornerstone of surgical treatment of men with urinary incontinence for several decades [1,3–6]. The device is recognized in numerous guidelines as the gold standard for managing moderate to severe urinary incontinence [1–3,6,7]. Despite its efficacy, the AUS may be accompanied by significant complications, such as urethral atrophy, urethral erosion, device malfunction, and infection, leading to surgical revision rates of up to 28% within five years [8–10]. Urethral instrumentation (UI) in patients with an AUS requires specific technical considerations [2,7,11]. It is crucial to deactivate the AUS during these procedures to maintain the urethral cuff in an open position [2,7,10]. Also, selecting appropriate catheter/equipment diameter for procedures like urethral catheterization, urodynamic studies, urethrocystoscopy, and ureteroscopy is important [2,7]. For bladder catheterization, a small diameter catheter (14 Fr or less) is recommended, and the duration of catheterization should be minimized [7,11,12]. Seideman et al . demonstrated an increased risk of urethral erosion in patients with an AUS catheterized for more than 48 hours [12]. Urethral erosion, particularly at the cuff site, is a major complication, that often necessitates device removal and urethral reconstruction [9]. Improper UI is a preventable cause of this complication and carries significant clinical and legal implications [11,12]. Therefore, it is important for urologists to be proficient in performing UI in men with an AUS [11]. Many urology residents across various countries report insufficient training in functional urology, contributing to their low confidence levels in this field [13,14]. Post-residency, many urologists discontinue managing patients with an AUS, as these surgeries are typically performed by specialists in functional urology [15]. This lack of ongoing experience is concerning, especially given that most urologists are on call for significant periods and may need to perform urgent UI in patients with an AUS. Our study hypothesized that many Brazilian urologists are not adequately trained to perform UI in patients with an AUS. To test this, we conducted a cross-sectional survey to assess the knowledge, prior experience, and self-declared competence of Brazilian urologists in performing UI in men with an AUS. METHODS This study was conducted as an electronic survey, sent through e-mail and/or telephone message to all members of the Brazilian Society of Urology, with no incentives for completion. The invitation for urologists to participate was distributed on September 16, 2023. Two additional invitations were sent on September 18 and 25, 2023. Data collection was closed on October 3rd, 2023. The invitation was sent to 3000 eligible urologists. It contained a link to a 19-question, web-based survey (Supplementary Material). Most questions were closed-ended, multiple choice. Some also allowed an open answer. The data obtained were anonymous and stored in a digital database. This study was approved by our hospital's Research Ethics Committee (project number CAAE: 71306523.2.0000.0068) and informed consent was obtained from all participants. The survey included an assessment of sociodemographic data, practice patterns, training in AUS manipulation received during medical residency, knowledge regarding AUS components and functionality, experience with UI of men with an AUS and knowledge about appropriate catheter diameter and duration. We also asked participants about their interest in receiving training for UI in patients with an AUS. The skills and knowledge regarding AUS components and manipulation assessed included the ability to identify the deactivation button, open the urethral cuff, and deactivate the device. We classified urologists as self-declared 'competent' in AUS manipulation if they had prior experience with UI in a patient with the device and felt confident in their ability to perform the procedure again if necessary. In relation to previous experience with UI in men with an AUS, we surveyed the circumstances requiring evaluation or instrumentation, the management conduct in these situations, and any previous attempts at UI performed by healthcare personnel prior to the urologist's evaluation. Data collection and statistical analysis Data were initially elaborated using Survey Monkey® software online. Quantitative variables were expressed as medians and interquartile ranges, while qualitative variables were expressed as absolute values, percentages, or proportions. Student's t or ANOVA was used to compare continuous variables. Categorical variables were compared using the Chi-square or Fisher's exact test. Associations were described as Odds ratios with respective confidence intervals. The analysis was performed using GraphPad Prism, version 10.0.01 for Windows, San Diego California USA. All tests were two sided and a p value < 0.05 considered statistically significant. RESULTS A total of 536 subjects (86.5% men) completed the survey, representing 17.9% of the Brazilian urologists who received the survey link. The median age of the participants was 47 years [39-55]. The sociodemographic data of the participants are shown in Table 1 . Among the respondents, 42.1% completed their residency more than 20 years ago, 24.0% completed it 10-20 years ago, and 33.9% completed it less than 10 years ago. Most respondents (95.0%) work at least part-time in private practice, while 326 (60.8%) work at least part-time in the public sector. Of the participants, 390 (72.8%) reported involvement in urological emergencies, with 279 (71.5%) involved at least one day per week, 82 (21.0%) at least one day per month, and 29 (7.5%) less than one day per month. Prior training and experience with AUS surgeries and UI Most respondents indicated a deficiency in training with AUS surgery and UI during their medical residency. Specifically, 335 (62.5%) participants reported receiving no training at all; 147 (27.4%) had minimal or insufficient training and 54 participants (10.1%) received adequate training during their residency ( Table 2 ). Regarding the number of AUS implant surgeries performed or assisted in over the last 5 years, 213 (39.7%) urologists reported not having performed or assisted in any procedures during this period. Among the 323 participants who did perform or assist in AUS implant surgeries, 164 (50.8%) reported an average of less than one surgery per year, 110 (34.0%) between one and five surgeries annually, and 49 (15.2%) reported more than five surgeries per year. Among the participants, 286 (53.4%) reported having previously performed UI in men with an AUS. Of these, 216 (75.5%) did so independently, while 70 (24.5%) sought assistance from a more experienced colleague. A total of 250 (46.6%) urologists responded they had never evaluated patients with an AUS necessitating UI. In previous situations where UI was performed, 133 urologists (42.2%) reported that they had performed the procedure in urgent or emergent circumstances. Among these, 36.2% indicated that the medical or nursing team had already attempted to manipulate the urethra before they intervened. A total of 102 (32.4%) urologists reported having performed the UI in an elective scenario, at the patient's request a few days before elective surgery, which required the deactivation of the device. Additionally, 80 (25.4%) urologists reported evaluating patients during hospital stay for elective surgeries. Knowledge, skills and self-declared competency related to UI in patients with AUS Among the respondents, 46.8% reported a thorough understanding of AUS components and operation, while 47.8% had partial knowledge, and 5.4% admitted to having no knowledge. The ability to identify the AUS deactivation button was reported by 85.2% of participants, with 46.4% able to open the urethral cuff and 45.1% competent in deactivating the AUS. Regarding urethral catheterization, 47.2% of respondents correctly selected the appropriate catheter diameter (8-14 Fr) for men with a deactivated AUS, 26.7% admitted they did not know the correct size, and 26.1% incorrectly answered that any catheter size could be used if the AUS was deactivated. For the safe duration of catheterization, 20.9% correctly identified that up to 48 hours is permissible, 44.7% admitted they did not know the safe duration, and 34.4% provided incorrect answers, suggesting safe durations of one week or longer ( Figure 1 ). Overall, 241 (45.1%) participants self-declared competence in UI in men with an AUS. Among them, 96 (39.8%) provided an incorrect answer regarding the appropriate diameter of the urethral catheter, and 128 (53.1%) provided an incorrect answer concerning the proper duration for urethral catheterization. Factors associated with self-declared competence in UI in men with an AUS are presented in Table 3 . The strongest associations were found with knowledge AUS components and functionality (OR 20 [95% CI: 12.8-31.1]), regular involvement with AUS implant surgeries (OR 11.7 [95% CI: 7.3-18.7]) and prior experience with UI in patients with an AUS (OR 10.0 [95% CI: 6.6 – 15.2]). Educational training aspirations Most participants (89.3%) expressed interest in additional training for UI in patients with an AUS. This included 81.7% of those who self-declared as competent and 95.3% of those who self-declared as not competent (p<0.001). Interest in additional training was lower among individuals who identified as specialists in urinary incontinence (82.4% vs. 92.2% for non-specialists; OR 0.4 [95% CI: 0.2-0.7]; p=0.005). DISCUSSION Several studies have assessed training and skills in performing different urological procedures [13–17]; however, to our knowledge this is the first study to specifically evaluate urologists' training regarding UI in patients with an AUS. The findings from our national survey highlight significant gaps in knowledge and training among Brazilian urologists regarding the manipulation of AUS. Given the high stakes involved in such procedures, including the risk of urethral erosion, this lack of preparedness has profound clinical and legal implications [7,11,18]. Most respondents reported being actively involved in emergency urological care and having received insufficient training for AUS manipulation during residency. The recognition of this deficiency is crucial for improving patient outcomes and minimizing potential complications associated with AUS manipulation. The 536 participants in this study represent 17.9% of the Brazilian urologists who received the survey link, offering valuable insights into their experiences, attitudes, and skills. This participation rate is relatively high compared to similar studies. Recent surveys have obtained participation rated varying from 8.1–18.2% from Brazilian urologists [15,19]. A recent study regarding the management of pelvic organ prolapse garnered 673 responses from urologists, gynaecologists, and urogynaecologists throughout Latin America [17]. A survey involving urologists associated with Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction and International Continence Society had only 86 participants [20]. We speculate that the relevance of UI in patients with an AUS to all urologists contributed to the high participation rate in this study. Interestingly, the demographics in our study, including gender, age, and geographical distribution, closely mirrored those in other studies with Brazilian urologists [19]. The practice patterns, with a majority in private practice and a significant number working in the public health system, along with the geographic spread and years of experience, suggest that our sample is representative of the broader Brazilian urology community, which enhances the validity of our findings. The concern with UI in patients with an AUS is not unique to Brazil but is reflective of a broader international context. Studies conducted in Europe and Asia have similarly indicated that Functional Urology is one of the specialties with the most precarious training [13,14]. Many studies have alerted for the need for appropriate UI to avoid complications [11,12,18,21]. This global pattern underscores the urgent need for enhanced training programs and continuing medical education to address these gaps, especially as new urinary sphincter devices and technologies are emerging [22]. Our data showed that a substantial proportion of urologists were not properly trained to perform UI in patients with an AUS during residency. Specifically, 62.5% of respondents reported no training in AUS manipulation during residency, and only 10.1% felt they had been adequately trained. This gap in training is reflected in the respondents' knowledge and self-declared competency levels. For example, only 46.8% had a thorough understanding of AUS components and functionality, and less than half of the respondents (45.1%) felt competent in AUS deactivation. These findings indicate that current residency programs may not sufficiently cover AUS-related procedures. The survey also revealed that many urologists who perform or assist in AUS implant surgeries do not frequently engage in such procedures, with 39.7% not having performed any AUS implant surgeries in the last five years and only 9.1% performing at least five surgeries per year. This limited exposure likely contributes to the low levels of confidence and competence reported. Interestingly, urologists who self-declared as competent in AUS manipulation were significantly more likely to have a higher surgical volume, indicating that practical experience is a key factor in developing proficiency. This correlation emphasizes the importance of hands-on training and regular practice to maintain and enhance skills. It is concerning that the deficiencies with AUS manipulation were observed among most urologists who work in urological emergencies settings. It is important to note that these urologists, even if they are not specialists in Functional Urology, may encounter clinical situations requiring UI for catheterization, urethrocystoscopy or ureteroscopy. A notable finding was the widespread lack of knowledge regarding appropriate catheter diameter and the safe duration for catheterization in patients with an AUS. Only 47.2% of respondents could correctly identify the appropriate catheter size, and almost 80% could not indicate the safe duration of catheterization. These specific knowledge gaps highlight areas where targeted education could have immediate and practical benefits. The high interest in further training (89.3% of respondents) suggests a strong willingness among urologists to improve their skills and knowledge related to AUS manipulation. This interest was particularly high among those who self-identified as non-competent, indicating a recognition of their deficiencies and a desire to address them. This finding presents an opportunity for professional organizations and educational institutions to develop and offer specialized training programs, workshops, and continuing education courses tailored to this need. It is both interesting and concerning that a significant percentage of self-declared competent urologists were unable to select the appropriate catheter diameter and determine the safe duration of urethral catheterization. Among the participants who considered themselves competent, 40% provided incorrect answers regarding the appropriate diameter of the urethral catheter, and 128 (53.1%) gave incorrect answers concerning the proper duration for urethral catheterization. Additionally, the high rate of interest (81.7%) in further training in AUS manipulation among these "competent" urologists suggests that the actual number of urologists prepared to perform UI in men with an AUS is probably lower than reported in this study. The present study has several limitations. The reliance on self-declared data may introduce selection bias, as respondents with a greater interest in the survey topic are more likely to participate. Additionally, there is a risk of respondents overestimating their knowledge or skills, as both competence and knowledge about the device's components were self-declared. Furthermore, the definition of a urinary incontinence specialist was self-declared, without requiring formal academic training or a specific number of procedures performed. Despite these limitations, this study is the first to specifically evaluate training and self-declared competency in the management of situations involving the AUS. Its uniqueness lies in its robust national sample size and comprehensive survey covering various aspects of UI in patients with an AUS. The study highlights the need for targeted educational initiatives to address the identified deficiencies, to enhance the competence and preparedness of urologists in managing patients with an AUS. The study may also instigate others to evaluate the situation in different countries, as many of our results seem to be universal. Future efforts should focus on developing educational programs to address the identified gaps and improve patient care standards. The strong interest in additional training expressed by most respondents, including those who self-declared as competent, indicates a recognition of the complexity of AUS management and a commitment to continuous learning within the urological community. CONCLUSIONS This study highlights a significant competence gap among Brazilian urologists regarding UI in patients with an AUS. This gap aligns with their expressed interest in receiving training. Our findings underscore the potential for enhancing patient outcomes and minimizing AUS-associated complications in Brazil and might be reflective of challenges in broader international contexts. Abbreviations AUS Artificial urinary sphincter CI Confidence interval OR Odds ratio UI Urethral instrumentation PPUI Posprostatectomy urinary incontinence RP Radical prostatectomy SUI Stress urinary incontinence Declarations Acknowledgment This study was funded by the Brazilian Society of Urology. Declaration of Interests Vicktor Bruno Pereira Pinto received a research grant from Coloplast during the conduct of this study. Cristiano M. Gomes serves as a consultant and lecturer for Boston Scientific, Astellas Pharma, Coloplast, Medtronic and Teleflex. Other authors declares that there are no conflicts of interest for this purpose. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Consent to Publish: All authors consent to publication. Funding : None Author Contribution VBPP wrote the main manuscript text and prepared the figures and tables. JBJ conducted the statistical analysis and assisted in the preparation of tables. JAPP helped in adjusting the terminology used and in developing the questionnaire. KMJA handled the ethical and logistical aspects of the study. JAF assessed the educational objectives and assisted in the adjustment of the ethical and logistical aspects. CMG conceived the research proposal and the structure of the manuscript, tables, and figures. All authors reviewed the manuscript. References Sandhu JS, Breyer B, Comiter C, Eastham JA, Gomez C, Kirages DJ, et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. Journal of Urology. 2019;202:369–78. Available from: http://www.auajournals.org/doi/10.1097/JU.0000000000000314 Averbeck M, Goldman H, Chung E, Collado Serra A, Comiter C, Guralnick M, et al. Surgery for male urinary incontinence. In: Cardozo L, Rovner E, Wagg A, Wein A, Abrams P, editors. Incontinence. 7th ed. 2023. p. 1183–291. 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Artificial urinary sphincter: recent developments and the way forward. Curr Opin Urol. 2024; Tables Table 1: Participants' demographic and practice patterns Age 47.6 ± 11.3 Gender Male Female 86.5% 13.5% Distribution by geographic Brazilian region Southeast South Northeast Central-West North 46.5% 24.3% 15.1% 7.6% 6.5% Time since residency completion 20 years 33.9% 24.0% 42.1% Workplace (admitted more than one option) Some affiliation with the private sector Some affiliation with the public sector 95.0% 60.8% Urological emergency coverage Yes No 72.8% 27.2% Self-declared specialists in urinary incontinence Yes No 19.5% 80.5% Table 2: Urologists' training and experience with the AUS and UI Training with AUS received during medical residency None Little/insufficient Adequate 62.5% 27.4% 10.1% AUS surgeries performed or assisted in the last 5 years None 5 surgery/year 39.7% 30.6% 20.5% 9.1% Self-declared knowledge of components and functioning of the AUS Knows the components and functioning of AUS well Partial knowledge of the components and functioning of AUS Does not know the components and functioning of the AUS 46.8% 47.8% 5.4% Management of patients with AUS needing UI Performed UI on their own Requested a more experienced urologist to handle the case Never evaluated patients with AUS needing UI 40.3 % 13.1% 46.6% Context in which was involved in the evaluation of patient with AUS Urgent situation Patient came electively, a few days before a procedure Patient hospitalized for elective surgery 42.2% 32.4% 25.4% Previous UI before urologist’s evaluation None Previous UI by medical/nursing team 63.8% 36.2% AUS: artificial urinary sphincter; UI: urethral instrumentation Table 3: Factors associated with self-declared competence in performing AUS deactivation Parameters Odds ratio [95% CI]* Knowledge of AUS components and functionality 20.0 [12.8-31.1] Regular involvement in AUS implant surgeries** 11.7 [7.3-18.7] Prior UI of patients with AUS 10.0 [6.6-15.2] Adequate training during residency 4.4 [2.3-8.4] Knowing proper duration of urethral catheterization 3.3 [2-2-4.8] Being a specialist in urinary incontinence 3.0 [1.9-4.9] Knowing appropriate caliber of urethral catheter 2.6 [1.8-3.7] AUS: artificial urinary sphincter; CI: confidence interval; UI: urethral instrumentation. *p<0.001 for all comparisons. **Participation in at least one AUS implant surgery per year Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 26 Oct, 2024 Reviews received at journal 23 Oct, 2024 Reviewers agreed at journal 23 Oct, 2024 Reviews received at journal 22 Oct, 2024 Reviewers agreed at journal 05 Sep, 2024 Reviewers invited by journal 02 Sep, 2024 Editor assigned by journal 30 Aug, 2024 Submission checks completed at journal 30 Aug, 2024 First submitted to journal 28 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4993232","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":353838254,"identity":"6d6e0ebe-94ee-4b89-9d98-2202053d8216","order_by":0,"name":"Vicktor Bruno Pereira Pinto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIie3QwUrDMBjA8W8Esksg14yJz5BRaB3sYVKEnrJdCtKD6KCwk+xc8CUGws6VYHfJAwQUEfcCBcHjMB0KFdqw4w75BxoC/bVJAHy+cwzZ0cR/14Ky48wunKRsk1EBg6UlxPmff4SbI4FewndoH9TZO0RjHX7UoBbBa777NLdXBIbqZdNFFA5EqVOYrmU0KUCl4VsV57KyGyNJYjrIKCeofF4J4JqEYwJJvDVykktsCSPhaeSpaMihn1BEkGiRWbxhlsxXLoIDrrWA6QO+sfc7S5lJ4sf5mhHccxZM1Z5lmYCIoC2rgS1ocV1+ye+7SzpUVRf5637ZPAeH9tccr/t8Pp/P3Q9Po1iO/doJ5QAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Vicktor","middleName":"Bruno Pereira","lastName":"Pinto","suffix":""},{"id":353838255,"identity":"79e91d2f-b78b-4b85-92a3-33d393772ed6","order_by":1,"name":"Jose de Bessa Jr","email":"","orcid":"","institution":"State University of Feira de Santana","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"","lastName":"de Bessa","suffix":"Jr"},{"id":353838256,"identity":"d18a694e-023e-4528-aa13-679550b5323a","order_by":2,"name":"José Antonio Penedo Prezotti","email":"","orcid":"","institution":"Hospital Santa Rita de Cássia","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Antonio Penedo","lastName":"Prezotti","suffix":""},{"id":353838257,"identity":"bcae7e6a-9301-4725-9a53-b2cacedf41e7","order_by":3,"name":"Karin Marise Jaeger Anzolch","email":"","orcid":"","institution":"Hospital Moinhos de Vento","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"Marise Jaeger","lastName":"Anzolch","suffix":""},{"id":353838258,"identity":"8da8edcd-cd45-4c76-ab96-0cb4eefbe1db","order_by":4,"name":"Jose Ailton Fernandes","email":"","orcid":"","institution":"Rio de Janeiro State University","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Ailton","lastName":"Fernandes","suffix":""},{"id":353838259,"identity":"c28a6a71-8980-432f-9735-70e0cad8e20b","order_by":5,"name":"Cristiano Mendes Gomes","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Cristiano","middleName":"Mendes","lastName":"Gomes","suffix":""}],"badges":[],"createdAt":"2024-08-28 19:35:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4993232/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4993232/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-024-05407-1","type":"published","date":"2024-12-18T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66939578,"identity":"84203ae8-c83e-4f90-9d0c-95941fc50470","added_by":"auto","created_at":"2024-10-18 08:41:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38326,"visible":true,"origin":"","legend":"\u003cp\u003eRates of Self-declared Competence and Knowledge in Key Aspects of UI in men with an AUS\u003c/p\u003e\n\u003cp\u003e*≤14Fr; **up to 1 week.6\u003c/p\u003e\n\u003cp\u003eUI: urethral instrumentation; AUS: artificial urinary sphincter; UC: urethral catheter\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-4993232/v1/8e2611b683bc162eee73f4c8.png"},{"id":72202079,"identity":"02ac90e4-5fb8-4283-8a07-072d67623cc6","added_by":"auto","created_at":"2024-12-23 16:14:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":609314,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4993232/v1/6592c3e0-3187-41c8-9b66-5c2a4fa001c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUrinary incontinence is a significant long-term complication of radical prostatectomy [1]. It has been estimated that approximately 5\u0026ndash;10% of men who undergo this procedure experience persistent urinary incontinence, necessitating surgical intervention [2]. The artificial urinary sphincter (AUS) has been the cornerstone of surgical treatment of men with urinary incontinence for several decades [1,3\u0026ndash;6]. The device is recognized in numerous guidelines as the gold standard for managing moderate to severe urinary incontinence [1\u0026ndash;3,6,7]. Despite its efficacy, the AUS may be accompanied by significant complications, such as urethral atrophy, urethral erosion, device malfunction, and infection, leading to surgical revision rates of up to 28% within five years [8\u0026ndash;10].\u003c/p\u003e \u003cp\u003eUrethral instrumentation (UI) in patients with an AUS requires specific technical considerations [2,7,11]. It is crucial to deactivate the AUS during these procedures to maintain the urethral cuff in an open position [2,7,10]. Also, selecting appropriate catheter/equipment diameter for procedures like urethral catheterization, urodynamic studies, urethrocystoscopy, and ureteroscopy is important [2,7]. For bladder catheterization, a small diameter catheter (14 Fr or less) is recommended, and the duration of catheterization should be minimized [7,11,12]. Seideman \u003cem\u003eet al\u003c/em\u003e. demonstrated an increased risk of urethral erosion in patients with an AUS catheterized for more than 48 hours [12].\u003c/p\u003e \u003cp\u003eUrethral erosion, particularly at the cuff site, is a major complication, that often necessitates device removal and urethral reconstruction [9]. Improper UI is a preventable cause of this complication and carries significant clinical and legal implications [11,12]. Therefore, it is important for urologists to be proficient in performing UI in men with an AUS [11].\u003c/p\u003e \u003cp\u003eMany urology residents across various countries report insufficient training in functional urology, contributing to their low confidence levels in this field [13,14]. Post-residency, many urologists discontinue managing patients with an AUS, as these surgeries are typically performed by specialists in functional urology [15]. This lack of ongoing experience is concerning, especially given that most urologists are on call for significant periods and may need to perform urgent UI in patients with an AUS.\u003c/p\u003e \u003cp\u003eOur study hypothesized that many Brazilian urologists are not adequately trained to perform UI in patients with an AUS. To test this, we conducted a cross-sectional survey to assess the knowledge, prior experience, and self-declared competence of Brazilian urologists in performing UI in men with an AUS.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study was conducted as an electronic survey, sent through e-mail and/or telephone message to all members of the Brazilian Society of Urology, with no incentives for completion. The invitation for urologists to participate was distributed on September 16, 2023. Two additional invitations were sent on September 18 and 25, 2023. Data collection was closed on October 3rd, 2023. The invitation was sent to 3000 eligible urologists. It contained a link to a 19-question, web-based survey (Supplementary Material). Most questions were closed-ended, multiple choice. Some also allowed an open answer.\u003c/p\u003e \u003cp\u003eThe data obtained were anonymous and stored in a digital database. This study was approved by our hospital's Research Ethics Committee (project number CAAE: 71306523.2.0000.0068) and informed consent was obtained from all participants.\u003c/p\u003e \u003cp\u003eThe survey included an assessment of sociodemographic data, practice patterns, training in AUS manipulation received during medical residency, knowledge regarding AUS components and functionality, experience with UI of men with an AUS and knowledge about appropriate catheter diameter and duration. We also asked participants about their interest in receiving training for UI in patients with an AUS.\u003c/p\u003e \u003cp\u003eThe skills and knowledge regarding AUS components and manipulation assessed included the ability to identify the deactivation button, open the urethral cuff, and deactivate the device. We classified urologists as self-declared 'competent' in AUS manipulation if they had prior experience with UI in a patient with the device and felt confident in their ability to perform the procedure again if necessary.\u003c/p\u003e \u003cp\u003eIn relation to previous experience with UI in men with an AUS, we surveyed the circumstances requiring evaluation or instrumentation, the management conduct in these situations, and any previous attempts at UI performed by healthcare personnel prior to the urologist's evaluation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection and statistical analysis\u003c/h2\u003e \u003cp\u003eData were initially elaborated using Survey Monkey\u0026reg; software online. Quantitative variables were expressed as medians and interquartile ranges, while qualitative variables were expressed as absolute values, percentages, or proportions. Student's t or ANOVA was used to compare continuous variables. Categorical variables were compared using the Chi-square or Fisher's exact test. Associations were described as Odds ratios with respective confidence intervals. The analysis was performed using GraphPad Prism, version 10.0.01 for Windows, San Diego California USA. All tests were two sided and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 536 subjects (86.5% men) completed the survey, representing 17.9% of the Brazilian urologists who received the survey link. The median age of the participants was 47 years [39-55]. The sociodemographic data of the participants are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Among the respondents, 42.1% completed their residency more than 20 years ago, 24.0% completed it 10-20 years ago, and 33.9% completed it less than 10 years ago. Most respondents (95.0%) work at least part-time in private practice, while 326 (60.8%) work at least part-time in the public sector. Of the participants, 390 (72.8%) reported involvement in urological emergencies, with 279 (71.5%) involved at least one day per week, 82 (21.0%) at least one day per month, and 29 (7.5%) less than one day per month.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrior training and experience with AUS surgeries and UI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents indicated a deficiency in training with AUS surgery and UI during their medical residency. Specifically, 335 (62.5%) participants reported receiving no training at all; 147 (27.4%) had minimal or insufficient training and 54 participants (10.1%) received adequate training during their residency (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eRegarding the number of AUS implant surgeries performed or assisted in over the last 5 years, 213 (39.7%) urologists reported not having performed or assisted in any procedures during this period. Among the 323 participants who did perform or assist in AUS implant surgeries, 164 (50.8%) reported an average of less than one surgery per year, 110 (34.0%) between one and five surgeries annually, and 49 (15.2%) reported more than five surgeries per year.\u003c/p\u003e\n\u003cp\u003eAmong the participants, 286 (53.4%) reported having previously performed UI in men with an\u0026nbsp;AUS.\u0026nbsp;Of these, 216 (75.5%) did so independently, while 70 (24.5%) sought assistance from a more experienced colleague. A total of 250 (46.6%) urologists responded they had never evaluated patients with an AUS necessitating UI.\u003c/p\u003e\n\u003cp\u003eIn previous situations where UI was performed, 133 urologists (42.2%) reported that they had performed the procedure in urgent or emergent circumstances. Among these, 36.2% indicated that the medical or nursing team had already attempted to manipulate the urethra before they intervened. A total of 102 (32.4%) urologists reported having performed the UI in an elective scenario, at the patient\u0026apos;s request a few days before elective surgery, which required the deactivation of the device. Additionally, 80 (25.4%) urologists reported evaluating patients during hospital stay for elective surgeries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge, skills and self-declared competency related to UI in patients with AUS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the respondents, 46.8% reported a thorough understanding of AUS components and operation, while 47.8% had partial knowledge, and 5.4% admitted to having no knowledge. The ability to identify the AUS deactivation button was reported by 85.2% of participants, with 46.4% able to open the urethral cuff and 45.1% competent in deactivating the AUS. Regarding urethral catheterization, 47.2% of respondents correctly selected the appropriate catheter diameter (8-14 Fr) for men with a deactivated AUS, 26.7% admitted they did not know the correct size, and 26.1% incorrectly answered that any catheter size could be used if the AUS was deactivated. For the safe duration of catheterization, 20.9% correctly identified that up to 48 hours is permissible, 44.7% admitted they did not know the safe duration, and 34.4% provided incorrect answers, suggesting safe durations of one week or longer (\u003cstrong\u003eFigure 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eOverall, 241 (45.1%) participants self-declared competence in UI in men with an AUS. Among them,\u0026nbsp;96 (39.8%) provided an incorrect answer regarding the appropriate diameter of the urethral catheter, and 128 (53.1%) provided an incorrect answer concerning the proper duration for urethral catheterization.\u003c/p\u003e\n\u003cp\u003eFactors associated with self-declared competence in UI in men with an AUS are presented in \u003cstrong\u003eTable 3\u003c/strong\u003e. The strongest associations were found with knowledge AUS components and functionality (OR 20 [95% CI:\u0026nbsp;12.8-31.1]), regular involvement with AUS implant surgeries (OR 11.7 [95% CI:\u0026nbsp;7.3-18.7]) and prior experience with UI in patients with an AUS (OR 10.0 [95% CI:\u0026nbsp;6.6 \u0026ndash; 15.2]).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducational training aspirations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants (89.3%) expressed interest in additional training for UI in patients with an AUS. This included 81.7% of those who self-declared as competent and 95.3% of those who self-declared as not competent (p\u0026lt;0.001). Interest in additional training was lower among individuals who identified as specialists in urinary incontinence (82.4% vs. 92.2% for non-specialists; OR 0.4 [95% CI: 0.2-0.7]; p=0.005).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSeveral studies have assessed training and skills in performing different urological procedures [13\u0026ndash;17]; however, to our knowledge this is the first study to specifically evaluate urologists' training regarding UI in patients with an AUS. The findings from our national survey highlight significant gaps in knowledge and training among Brazilian urologists regarding the manipulation of AUS. Given the high stakes involved in such procedures, including the risk of urethral erosion, this lack of preparedness has profound clinical and legal implications [7,11,18]. Most respondents reported being actively involved in emergency urological care and having received insufficient training for AUS manipulation during residency. The recognition of this deficiency is crucial for improving patient outcomes and minimizing potential complications associated with AUS manipulation.\u003c/p\u003e \u003cp\u003eThe 536 participants in this study represent 17.9% of the Brazilian urologists who received the survey link, offering valuable insights into their experiences, attitudes, and skills. This participation rate is relatively high compared to similar studies. Recent surveys have obtained participation rated varying from 8.1\u0026ndash;18.2% from Brazilian urologists [15,19]. A recent study regarding the management of pelvic organ prolapse garnered 673 responses from urologists, gynaecologists, and urogynaecologists throughout Latin America [17]. A survey involving urologists associated with Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction and International Continence Society had only 86 participants [20]. We speculate that the relevance of UI in patients with an AUS to all urologists contributed to the high participation rate in this study. Interestingly, the demographics in our study, including gender, age, and geographical distribution, closely mirrored those in other studies with Brazilian urologists [19]. The practice patterns, with a majority in private practice and a significant number working in the public health system, along with the geographic spread and years of experience, suggest that our sample is representative of the broader Brazilian urology community, which enhances the validity of our findings.\u003c/p\u003e \u003cp\u003eThe concern with UI in patients with an AUS is not unique to Brazil but is reflective of a broader international context. Studies conducted in Europe and Asia have similarly indicated that Functional Urology is one of the specialties with the most precarious training [13,14]. Many studies have alerted for the need for appropriate UI to avoid complications [11,12,18,21]. This global pattern underscores the urgent need for enhanced training programs and continuing medical education to address these gaps, especially as new urinary sphincter devices and technologies are emerging [22].\u003c/p\u003e \u003cp\u003eOur data showed that a substantial proportion of urologists were not properly trained to perform UI in patients with an AUS during residency. Specifically, 62.5% of respondents reported no training in AUS manipulation during residency, and only 10.1% felt they had been adequately trained. This gap in training is reflected in the respondents' knowledge and self-declared competency levels. For example, only 46.8% had a thorough understanding of AUS components and functionality, and less than half of the respondents (45.1%) felt competent in AUS deactivation. These findings indicate that current residency programs may not sufficiently cover AUS-related procedures.\u003c/p\u003e \u003cp\u003eThe survey also revealed that many urologists who perform or assist in AUS implant surgeries do not frequently engage in such procedures, with 39.7% not having performed any AUS implant surgeries in the last five years and only 9.1% performing at least five surgeries per year. This limited exposure likely contributes to the low levels of confidence and competence reported. Interestingly, urologists who self-declared as competent in AUS manipulation were significantly more likely to have a higher surgical volume, indicating that practical experience is a key factor in developing proficiency. This correlation emphasizes the importance of hands-on training and regular practice to maintain and enhance skills.\u003c/p\u003e \u003cp\u003eIt is concerning that the deficiencies with AUS manipulation were observed among most urologists who work in urological emergencies settings. It is important to note that these urologists, even if they are not specialists in Functional Urology, may encounter clinical situations requiring UI for catheterization, urethrocystoscopy or ureteroscopy.\u003c/p\u003e \u003cp\u003eA notable finding was the widespread lack of knowledge regarding appropriate catheter diameter and the safe duration for catheterization in patients with an AUS. Only 47.2% of respondents could correctly identify the appropriate catheter size, and almost 80% could not indicate the safe duration of catheterization. These specific knowledge gaps highlight areas where targeted education could have immediate and practical benefits.\u003c/p\u003e \u003cp\u003eThe high interest in further training (89.3% of respondents) suggests a strong willingness among urologists to improve their skills and knowledge related to AUS manipulation. This interest was particularly high among those who self-identified as non-competent, indicating a recognition of their deficiencies and a desire to address them. This finding presents an opportunity for professional organizations and educational institutions to develop and offer specialized training programs, workshops, and continuing education courses tailored to this need.\u003c/p\u003e \u003cp\u003eIt is both interesting and concerning that a significant percentage of self-declared competent urologists were unable to select the appropriate catheter diameter and determine the safe duration of urethral catheterization. Among the participants who considered themselves competent, 40% provided incorrect answers regarding the appropriate diameter of the urethral catheter, and 128 (53.1%) gave incorrect answers concerning the proper duration for urethral catheterization. Additionally, the high rate of interest (81.7%) in further training in AUS manipulation among these \"competent\" urologists suggests that the actual number of urologists prepared to perform UI in men with an AUS is probably lower than reported in this study.\u003c/p\u003e \u003cp\u003eThe present study has several limitations. The reliance on self-declared data may introduce selection bias, as respondents with a greater interest in the survey topic are more likely to participate. Additionally, there is a risk of respondents overestimating their knowledge or skills, as both competence and knowledge about the device's components were self-declared. Furthermore, the definition of a urinary incontinence specialist was self-declared, without requiring formal academic training or a specific number of procedures performed. Despite these limitations, this study is the first to specifically evaluate training and self-declared competency in the management of situations involving the AUS. Its uniqueness lies in its robust national sample size and comprehensive survey covering various aspects of UI in patients with an AUS. The study highlights the need for targeted educational initiatives to address the identified deficiencies, to enhance the competence and preparedness of urologists in managing patients with an AUS. The study may also instigate others to evaluate the situation in different countries, as many of our results seem to be universal. Future efforts should focus on developing educational programs to address the identified gaps and improve patient care standards. The strong interest in additional training expressed by most respondents, including those who self-declared as competent, indicates a recognition of the complexity of AUS management and a commitment to continuous learning within the urological community.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study highlights a significant competence gap among Brazilian urologists regarding UI in patients with an AUS. This gap aligns with their expressed interest in receiving training. Our findings underscore the potential for enhancing patient outcomes and minimizing AUS-associated complications in Brazil and might be reflective of challenges in broader international contexts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eAUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003eArtificial urinary sphincter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003e\u003cem\u003eOdds ratio\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003eUrethral instrumentation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003ePPUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003ePosprostatectomy urinary incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003eRadical prostatectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1307%;\"\u003e\n \u003cp\u003eSUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88.8693%;\"\u003e\n \u003cp\u003eStress urinary incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Brazilian Society of Urology.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVicktor Bruno Pereira Pinto received a research grant from Coloplast during the conduct of this study.\u003c/p\u003e\n\u003cp\u003eCristiano M. Gomes serves as a consultant and lecturer for Boston Scientific, Astellas Pharma, Coloplast, Medtronic and Teleflex.\u003c/p\u003e\n\u003cp\u003eOther authors declares that there are no conflicts of interest for this purpose.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent to publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: None\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVBPP wrote the main manuscript text and prepared the figures and tables. JBJ conducted the statistical analysis and assisted in the preparation of tables. JAPP helped in adjusting the terminology used and in developing the questionnaire. KMJA handled the ethical and logistical aspects of the study. JAF assessed the educational objectives and assisted in the adjustment of the ethical and logistical aspects. CMG conceived the research proposal and the structure of the manuscript, tables, and figures. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSandhu JS, Breyer B, Comiter C, Eastham JA, Gomez C, Kirages DJ, et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. Journal of Urology. 2019;202:369\u0026ndash;78. Available from: http://www.auajournals.org/doi/10.1097/JU.0000000000000314\u003c/li\u003e\n\u003cli\u003eAverbeck M, Goldman H, Chung E, Collado Serra A, Comiter C, Guralnick M, et al. Surgery for male urinary incontinence. In: Cardozo L, Rovner E, Wagg A, Wein A, Abrams P, editors. Incontinence. 7th ed. 2023. p. 1183\u0026ndash;291.\u003c/li\u003e\n\u003cli\u003eCornu JN, Gacci M, Hashim H, Herrmann TRW, Malde S, Netsch C, et al. EAU Non neurogenic male LUTS 2023. EAU Guidelines on Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl Benign Prostatic Obstruction (BPO). 2023;\u003c/li\u003e\n\u003cli\u003eGomes CM, Broderick GA, S\u0026aacute;nchez-Ortiz RF, Preate D, Rovner ES, Wein AJ. Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome. Journal of Urology. 2000;163:87\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eTrigo Rocha F, Gomes CM, Mitre AI, Arap S, Srougi M. A Prospective Study Evaluating the Efficacy of the Artificial Sphincter AMS 800 for the Treatment of Postradical Prostatectomy Urinary Incontinence and the Correlation Between Preoperative Urodynamic and Surgical Outcomes. Urology. 2008;71:85\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBhatt NR, Pavithran A, Ilie C, Smith L, Doherty R. Post‐prostatectomy incontinence: a guideline of guidelines. BJU Int. 2024;133:513\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eBiardeau X, Aharony S, Campeau L, Corcos J. Artificial Urinary Sphincter: Report of the 2015 Consensus Conference. Neurourol Urodyn. 2016;35.\u003c/li\u003e\n\u003cli\u003eSrivastava A, Joice GA, Patel HD, Manka MG, Sopko NA, Wright EJ. Causes of Artificial Urinary Sphincter Failure and Strategies for Surgical Revision: Implications of Device Component Survival. Eur Urol Focus. 2019;5:887\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eLinder BJ, De Cogain M, Elliott DS. Long-term device outcomes of artificial urinary sphincter reimplantation following prior explantation for erosion or infection. Journal of Urology. 2014;191:734\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eMartins FE, Boyd SD. Post‐operative risk factors associated with artificial urinary sphincter infection‐erosion. Br J Urol. 1995;75:354\u0026ndash;8. Available from: https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.1995.tb07348.x\u003c/li\u003e\n\u003cli\u003eBoscolo-Berto R, Raduazzo DI, Cecchetto G, Viel G. Urethral catheterization in men with artificial urinary sphincter: clinical and legal implications. Urol J. 2012;9:611\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eSeideman CA, Zhao LC, Hudak SJ, Mierzwiak J, Adibi M, Morey AF. Is Prolonged Catheterization a Risk Factor for Artificial Urinary Sphincter Cuff Erosion? Urology. 2013;82:943\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eCarrion DM, Rodriguez-Socarr\u0026aacute;s ME, Mantica G, Esperto F, Cebulla A, Duijvesz D, et al. Current status of urology surgical training in Europe: an ESRU\u0026ndash;ESU\u0026ndash;ESUT collaborative study. World J Urol. 2020;38:239\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eDoğan Değer M, Alperen Yıldız H, Denizhan Demirkıran E, Madendere S. Current status of urological training and differences between institutions. Actas Urol\u0026oacute;gicas Espa\u0026ntilde;olas (English Edition). 2022;46:285\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eCosta-Matos A, Toledo LGM, Fornari A, Fernandes Silva JA, Gomes CM. Functional urology: Practice patterns and training aspirations among urologists in Brazil. Neurourol Urodyn. 2022;41:1890\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMacCraith E, Forde JC, O\u0026rsquo;Brien FJ, Davis NF. Contemporary trends for urological training and management of stress urinary incontinence in Ireland. Int Urogynecol J. 2021;32:2841\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003ePlata M, Bravo-Balado A, Robledo D, Casta\u0026ntilde;o JC, Averbeck MA, Plata MA, et al. Trends in pelvic organ prolapse management in Latin America. Neurourol Urodyn. 2018;37:1039\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eKhoury JM, Webster GD, Perez LM. Urethral cuff erosion as a result of urinary catheterization in patients with an artificial urinary sphincter. N C Med J. 1994;55:162\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eGomes CM, Favorito LA, Henriques JVT, Canalini AF, Anzolch KMJ, Fernandes R de C, et al. Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists. International Braz J Urol. 2020;46:1042\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eWelk B, McGarry P, Baverstock R, Carlson K, Hickling D. Do Urodynamic Findings Other Than Outlet Obstruction Influence the Decision to Perform a Transurethral Resection of Prostate? Urology. 2018;117:120\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eOtis‐Chapados S, Kim J, Radomski SB. Artificial urinary sphincter cuffs and safe instrument/catheter passage guidelines. Neurourol Urodyn. 2022;41:1764\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eReus C, Tran S, Mozer P, Lenfant L, Beaugerie A, Chartier-Kastler E. Artificial urinary sphincter: recent developments and the way forward. Curr Opin Urol. 2024;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eParticipants\u0026apos; demographic and practice patterns\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e47.6 \u0026plusmn; 11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86.5%\u003c/p\u003e\n \u003cp\u003e13.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistribution by geographic Brazilian region\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSoutheast\u003c/p\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003cp\u003eNortheast\u003c/p\u003e\n \u003cp\u003eCentral-West\u003c/p\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46.5%\u003c/p\u003e\n \u003cp\u003e24.3%\u003c/p\u003e\n \u003cp\u003e15.1%\u003c/p\u003e\n \u003cp\u003e7.6%\u003c/p\u003e\n \u003cp\u003e6.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since residency completion\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt; 10 years\u003c/p\u003e\n \u003cp\u003e10-20 years\u003c/p\u003e\n \u003cp\u003e\u0026gt; 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.9%\u003c/p\u003e\n \u003cp\u003e24.0%\u003c/p\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorkplace (admitted more than one option)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSome affiliation with the private sector\u003c/p\u003e\n \u003cp\u003eSome affiliation with the public sector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e95.0%\u003c/p\u003e\n \u003cp\u003e60.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrological emergency coverage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.8%\u003c/p\u003e\n \u003cp\u003e27.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79.064%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-declared specialists in urinary incontinence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.936%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19.5%\u003c/p\u003e\n \u003cp\u003e80.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Urologists\u0026apos; training and experience with the AUS and UI\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraining with AUS received during medical residency\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eLittle/insufficient\u003c/p\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e62.5%\u003c/p\u003e\n \u003cp\u003e27.4%\u003c/p\u003e\n \u003cp\u003e10.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUS surgeries performed or assisted in the last 5 years\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003e\u0026lt; 1 surgery/year\u003c/p\u003e\n \u003cp\u003e1-5 surgeries/year\u003c/p\u003e\n \u003cp\u003e\u0026gt; 5 surgery/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39.7%\u003c/p\u003e\n \u003cp\u003e30.6%\u003c/p\u003e\n \u003cp\u003e20.5%\u003c/p\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-declared knowledge of components and functioning of the AUS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eKnows the components and functioning of AUS well\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePartial knowledge of the components and functioning of AUS\u003c/p\u003e\n \u003cp\u003eDoes not know the components and functioning of the AUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46.8%\u003c/p\u003e\n \u003cp\u003e47.8%\u003c/p\u003e\n \u003cp\u003e5.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement of patients with AUS needing UI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePerformed UI on their own\u003c/p\u003e\n \u003cp\u003eRequested a more experienced urologist to handle the case\u003c/p\u003e\n \u003cp\u003eNever evaluated patients with AUS needing UI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40.3 %\u003c/p\u003e\n \u003cp\u003e13.1%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;46.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext in which was involved in the evaluation of patient with AUS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUrgent situation\u003c/p\u003e\n \u003cp\u003ePatient came electively, a few days before a procedure\u003c/p\u003e\n \u003cp\u003ePatient hospitalized for elective surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;42.2%\u003c/p\u003e\n \u003cp\u003e32.4%\u003c/p\u003e\n \u003cp\u003e25.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87.0588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious UI before urologist\u0026rsquo;s evaluation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003ePrevious UI by medical/nursing team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9412%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.8%\u003c/p\u003e\n \u003cp\u003e36.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAUS: artificial urinary sphincter; UI: urethral instrumentation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Factors associated with self-declared competence in performing AUS deactivation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOdds ratio\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;[95% CI]*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of AUS\u003c/strong\u003e \u003cstrong\u003ecomponents and functionality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e20.0 [12.8-31.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003eRegular involvement in AUS implant surgeries**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e11.7 [7.3-18.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003ePrior UI of patients with AUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e10.0 [6.6-15.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003eAdequate training during residency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e4.4 [2.3-8.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003eKnowing proper duration of urethral catheterization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e3.3 [2-2-4.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003eBeing a\u0026nbsp;specialist\u0026nbsp;in urinary incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e3.0 [1.9-4.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.6722%;\"\u003e\n \u003cp\u003eKnowing appropriate caliber of urethral catheter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.3278%;\"\u003e\n \u003cp\u003e2.6 [1.8-3.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAUS: artificial urinary sphincter; CI: confidence interval; UI: urethral instrumentation.\u003c/p\u003e\n\u003cp\u003e*p\u0026lt;0.001 for all comparisons.\u003c/p\u003e\n\u003cp\u003e**Participation in at least one AUS implant surgery per year\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Artificial urinary sphincter, Urinary Incontinence, Male, Prostatectomy, Medical Education, Surveys and Questionnaires","lastPublishedDoi":"10.21203/rs.3.rs-4993232/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4993232/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eUrethral instrumentation (UI) in patients with an artificial urinary sphincter (AUS) demands technical considerations and poses a risk of urethral erosion, leading to serious clinical and legal consequences. We conducted a national survey to evaluate the knowledge and experience of Brazilian urologists with UI in these patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study used an electronic survey distributed to members of the Brazilian Society of Urology. The survey included 19 multiple-choice questions assessing sociodemographic characteristics, practice patterns, AUS training, knowledge of AUS components and functionality, experience with UI in AUS patients, and interest in further training. Urologists were classified as 'competent' in AUS manipulation if they had prior experience and confidence in performing UI.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 536 participants (median age 47 years [39\u0026ndash;55]), 72.8% reported involvement in urological emergencies, with 89.9% indicating inadequate AUS training during residency. Only 29.7% had occasional or regular involvement with AUS surgeries. Of the participants, 53.4% had performed UI in men with an AUS. Prior UI had been attempted by healthcare staff in 36.2% of cases. Only 46.8% reported knowledge of AUS components and 45.1% felt competent in deactivating it. Regarding urethral catheterization, 47.2% knew the safe catheter diameter, and 20.9% identified safe catheterization duration. Overall, 45.1% self-declared competence in UI, yet many gave incorrect answers on catheter size and duration. Competence strongly correlated with knowledge of AUS components, regular implant involvement, and prior experience. Most (89.3%) expressed interest in additional training for UI.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights significant gaps in training and knowledge among Brazilian urologists regarding UI in AUS patients. These deficiencies underscore the potential for enhanced education to improve patient outcomes and reduce AUS-associated complications in Brazil and possibly broader international contexts.\u003c/p\u003e","manuscriptTitle":"Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-18 08:41:22","doi":"10.21203/rs.3.rs-4993232/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-26T13:26:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-23T22:13:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67481355723144287406158131359819782349","date":"2024-10-23T22:11:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-23T00:49:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99866300115432257830967415617816374192","date":"2024-09-05T22:31:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-03T02:16:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-30T16:24:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-30T15:32:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2024-08-28T19:33:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"173ada8c-06c4-4695-bf55-d96de5c979c3","owner":[],"postedDate":"October 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:08:02+00:00","versionOfRecord":{"articleIdentity":"rs-4993232","link":"https://doi.org/10.1007/s00345-024-05407-1","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2024-12-18 15:58:00","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-10-18 08:41:22","video":"","vorDoi":"10.1007/s00345-024-05407-1","vorDoiUrl":"https://doi.org/10.1007/s00345-024-05407-1","workflowStages":[]},"version":"v1","identity":"rs-4993232","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4993232","identity":"rs-4993232","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}