Artificial Urinary Sphincter: Techniques and Complications

Case Seen By: Dr. Niall Heney, M.D. Dr. Boris Gershman, M.D. Department of Urology, Massachusetts General Hospital Harvard Medical School
Case Presented by: Aaron Desai, Medical Student

HPI
A 41 yo male with a history of Spina bifida/myelomeningocele and bladder augmentation presented with urinary incontinence s/p placement of artificial urinary sphincter x 2. Describes as life changing urinary incontinence x 6 months.

Continues to be significantly incontinent though does urinate approximately 3-4 times on a daily basis but does leak in between voids.
ROS: as above

Past Medical/Surgical History

Spina bifida/myelomeningocele/hydrocephalus
Bladder augmentation-? ureteral reimplantation
Artificial Urinary sphincter at bladder neck x 2. First done in 1996 and replaced in 2002.

Kidney Stones
Scoliosis surgery- 3 rods in back 1980s

Physical Examination
Middle aged man, overweight, wheelchair bound He has significant Scoliosis Anterior rotation of Pelvis

Oriented x 3
Remaining Examination: Unremarkable

Studies
CT Scan:
Showed No fluid in the reservoir

Cystoscopy
Showed no erosion of the urethra No evidence of sphincter cuff compression of urethra

AUS Techniques
Types:
Bulbar AUS
Perineal Approach Transscrotal Approach

Bladder Neck AUS

Abdominal Approach

Tandem Cuff AUS

Perineal Approach

The AUS cuff is most commonly placed around the bulbar urethra through a perineal incision Aim:
To place the cuff as proximal on the bulbar urethra as possible proximal to the fusion of the two corporeal bodies

Postoperative deactivation of the cuff for 4 to 6 weeks is essential for proper healing without erosion.

AUS
Box indicates appropriate location of AUS cuff

Perineal Approach

Tandem Cuff AUS

Transscrotal Approach

Pump in Scrotum

Bladder Neck AUS

Indication: Men with sphincteric UI in whom the prostate is without external surgical or traumatic disruption. Thus for, exstrophy/epispadias, myelomeningocele, and other neuropathic disorders, it should be considered before bulbar AUS Contraindication: After Radical Prostatectomy Advantages: Lower likelihood of erosion and cuff atrophy Requires a much larger cuff implant (usually 8 cm or greater), higher PRB pressure (usually 71 to 80 cm H2O), and a larger fluid volume in the system.

Complications of AUS
Urinary Retention: Immediate postoperative period: managed by transurethral bladder drainage with a small (10-Fr or 12-Fr) catheter for 24 to 48 hours. Cuff deactivation must be confirmed before catheterization. If the patient fails a voiding trial at 48 hours, supra-pubic drainage is considered to reduce the risk of urethral erosion AUS Infection: Initial presentation: scrotal pain, although erythema, edema, and frank purulence will commonly accompany this symptom. Implant infections: not amenable to antibiotics, so t/t explantation. Immediate salvage of infected non eroded AUS can be accomplished with complete device removal, antiseptic irrigation, and immediate reimplantation

Complications (continued)
Urethral Erosion: Delayed deactivation has lowered the risk of erosion Immediate removal of all the components as they are assumed to be infected. Re-implantation considered: after urethral healing is confirmed and a delay of 3 to 6 months is observed. New cuff: Placed either proximal or distal to the previous site.
Urethral Atrophy: Cause: chronic compression of the spongy tissue under the occlusive cuff. Most common reason for revision of the AUS. Treatment: cuff downsizing, movement of the cuff to a more proximal or distal location, or placement of a second cuff in tandem.

Complications (continued)
Mechanical failure:
15% Incidence Replacement of an isolated malfunctioning component may be feasible if the revision occurs within 3 years of implantation A slow leak from the PRB may be difficult to diagnose intraoperatively, and, if in doubt, total device replacement is prudent Devices greater than 3 years old should be replaced in toto.

Thank You