Table 1: Comparison between advantage and disadvantage of synchronous and nonsynchronous dual prosthetic insertion [717].

Synchronous dual implantationSequential dual implantation

AdvantagesAdvantages

(i) Single incision
(ii) Faster operating time
(iii) Single anaesthetic event
(iv) Shorter hospital stay
(v) Decreased overall recovery time
(vi) Increased cost savings
(vii) Theoretical reduction in the infection risk
(viii) Supine position allowing more mobility of the bulbar urethra facilitating posterior dissection
(ix) Easier placement of the AUS pump
(x) Decrease in the risk of AUS pump migration
(i) More time allowed for a patient to accommodate the first device before considering a second implant
(ii) Theoretical decreased initial confusion to operate the device
(iii) For AUS, there appears to be a higher completely dry rate and fewer subsequent tandem cuff additions when placed at a more robust proximal bulb of the urethra during a perineal incision

DisadvantagesDisadvantages

(i) Sufficient patient dexterity needed to activate either pump as required
(ii) Theoretical concerns of patient confusion and difficulty of use with two scrotal pumping devices
(iii) Surgeon experience and learning curve. Requires more experienced prosthetic urologists
(iv) If the bulbar urethra is considered difficult through the scrotal incision, the surgeon should use the perineal incision for the cuff placement
(v) Infection would potentially necessitate removal of both implants components
(vi) Concerns over the extent of dissection which may further increase the risks of erosion and infection
(vii) Distal placement of the AUS cuff on the thin urethra may be less effective, with a higher early failure rate and revisions due to loosely fitting cuffs and accelerated urethral atrophy
(i) Two incisions
(ii) Previous prosthetic implant may have asymptomatic colonization of the prosthetic device predisposing to infection during insertion of the second implant
(iii) Extra care is needed to avoid damaging the components of the existing implant and its tubing
(iv) Added danger of operating in an area with surgical scarring
(v) Insertion of the sphincter pump from an abdominal incision can be associated with excessive edema or hematoma causing the pump to retract into the upper groin, making long-term use by the patient difficult (high riding pump)