Alan Wein: Hi there, I'm Alan Wein from UroToday, and it's my great pleasure today to be interviewing Craig Comiter, who's like the guru of male urinary incontinence, which basically boils down except for overactive bladder to really stress urinary incontinence.

Craig Comiter: Artificial sphincter is a more reliable outcome, but it has a higher risk. So greater than 90% of patients are satisfied with the artificial sphincter. And it's a circumferential cuff that goes around the urethra, squeezes it to prevent leakage, and then the cuff is cycled to an open position during the time of voiding. And over the long term, 20% never leak, 55% leak a few drops, and an additional 22% leak less than a teaspoon for an overall success rate, about 90% using one pad or less per day.

And this has been shown to work long-term with a general decrease in efficacy in the very long-term due to cuff atrophy or urethral atrophy. And these can be replaced and we regain equal efficacy with replacement of the device. So what's new? What's coming down the road or what's FDA approved and becoming more popular?

Well, the ATOMS Sling is a transobturator sling, not available in the US, but under FDA trial. And this transobturator sling has an inflatable sub-urethral pillow for a boost of incontinence treatment. The ProACT is an adjustable balloon therapy, and this is periurethral balloons that go up near the bladder neck. They're placed percutaneously. There's a fillable scrotal port. These are indeed FDA approved and starting to gain traction in the country.

The electronic artificial sphincter is the obvious next step for the hydraulic device, where there could be a remote control and rather than a pressure regulating balloon, there could be a metal can that holds the fluid, and this would never lose elasticity. There are two brands under trial. The Artus, which uses a piano mode cuff instead of just a single cuff, it's two cuffs that can work in different modes to reduce the risk of cuff atrophy. And the UroActive is currently under trial in Europe and the United States. And this would be the E-AUS, the electronic AUS that has all the software that could do basically anything we would want.

Turn it off when you're recumbent to lower pressure and urethral atrophy, have an automatic timer release for a patient who may have forgotten to cycle, and also a software feature that may even allow the device to open if it senses an oncoming catheter.

So why do we even think about adjustability and innovation in a field where we're pretty successful? The answer is many of the patients are radiated. In fact, I don't do a lot of non-radiated patients anymore because they simply don't leak that much. So the patients are radiated and the simple transobturator sling is not efficacious in that group. And then you can see by the graph on the left after several years, we have decreased efficacy. Or you can simply call it progression of disease. I don't call it a five-year failure of the sling. I call it a five-year success.

There's just ongoing sphincteric insufficiency with muscle aging and sarcopenia, and you have progressive stress incontinence that requires further therapy, thus the spirit of the adjustability. And you can see there's the ARGUS sling available in Europe and that uses washers to tension it. There's the ATOMS sling that has this inflatable pillow along the perineal portion of the urethra, and then there's the REMEX sling, which has the veritensor and you can tighten the screws to lift up the sling a little further.