2. Indications
• Sphincteric incontinence in males
• m/c – post RP – prevalence of 2.5% to 40%
• Observation for 6-12mon with PFME
• For moderate-severe/gravitational UI
Additional factors to consider
• Severity of UI & associated bother
• Patient characteristics – BMI, prior Sx, radiation
therapy
3. • Bladder function
• Cystoscopic findings
• Manual dexterity & cognitive function
• Efficacy of various implants
• Long-term risk for complications & reoperation
• Patient preference
4. Contraindications
Absolute
• High-risk bladder – ↓compliance, VUR at low pressure
• Tissue integrity to accommodate AUS lacking
Relative
• Transurethral access required –
– bladder cancer
– refractory vesicourethral anastomotic strictures
• Metastatic prostate cancer – not a contraindication
5.
6.
7.
8. History
• 1947 – Foley – first AUS → externally worn urethral
cuff attached to a pump kept in patient’s pocket
• 1972 – Scott – AS-721 – Implanted (Bulky device)
– Fluid reservoir
– Inflatable occlusive cuff with unidirectional valve
– Right-sided inflation bulb
– Left-sided deflation bulb
9. • High cuff pressures → high rate of mechanical failure
→ high urethral erosion rates
• AS-761 – Pressure-regulating balloon (PRB) b/w cuff
& valve to counter high pressures
10. • 1974 – AS-742
• Balloon pressure reservoir for the cuff fluid
• first prosthesis with automatic cuff closure
• Delay-fill resistor – slowed return of fluid to the cuff
→ patient voids completely before cuff-closure
• Elimination of inflation pump
– easier implantation
11. • 1979 – AS 791(bulbar) & 792(bladder-neck)
• Resistor & valves in same case – fewer components
• Device always activated unless patient was voiding
• required an additional surgery for activation
• Constant pressure on urethra
→ high erosion rates
12. 1983 – AMS 800 (American Medical Systems)
• Added a deactivation button
– Allows the cuff to have an on-and-off function
– Cuff deflated postop to allow healing for 6-8 weeks
– Decreases erosion rate & obviates a 2nd activation Sx
• Moved valves & resistor into pump chamber, making
it a single component
• 1987 – narrowback cuff → improved focal pressure
on urethra, decreasing erosion
19. Patient Preparation
• AMA – Aminoglycoside + 1st /2nd Gen Cephalosporine
• Bulbar urethra is the preferred location
• Approaches –
– Perineal – Lithotomy position
– Trans-scrotal (Wilson et al.) – Supine position
– Modified lithotomy position (Petrou et al.) – TS-AUS
• Perineal approach preffered
20. Preferred location for bulbar cuff –
Proximal to convergence of corpora
cavernosa
Safe circumferential dissection of the
urethra
Protection of cuff from activation
while sitting
21. • PUC placed – 14Fr
– empty bladder
– ease urethral identification & dissection
• Scrotum elevated with towel-clips/sutures
• Anus excluded from the field with secure drapes
22. Device Preparation
• Remove air and fill with NS/diluted contrast
• Lock & unlock the control pump several times
• PRB – 61-70cmH2O (Standard)
– 51-60cmH2O (post-radiation)
• InhibiZone impregnation –
– combination of minocycline & rifampin
– No added benefit, but costly
– Do not put inhibizone impregnated device in NS (leaching)
25. Cuff Placement
• The m/c cuff size – 4.0cm → 65-80% case
• If PUC > 14Fr used → remove before cuff sizing
• Cuff should fit snugly without constricting urethra
• Cuff placement – mesh backing toward outside &
pillow side toward urethra
• The cuff is rotated laterally off midline
• Urethral injury → Repair → Abandon procedure
26.
27. PRB placement
• PRB placed via scrotal, perineal, or abdominal incision
• m/c – transverse inguinal incision
• Drain bladder before dissection to avoid injury
• Preperitoneal/Retropubic pocket
• PRB can be placed through external inguinal ring by
penetrating the floor of the inguinal canal
• Filled using 15G blunt-tipped syringe
29. Scrotal Pump placement
• Same incision as PRB, or separate scrotal incision
• Subdartos pocket that is –
– Easily accessible to the patient
– Away from the testis
– With minimal overlying tissue
• Pocket everted to ensure hemostasis
• Deactivation button out towards skin
30. Connections
• Cuff tubing passed to inguinal
incision
• Quick connect device used for
connections
• The excess tubing trimmed
• All connections remain in
inguinal region
31. Device setting & Closure
• Pump cycled 2-3 times to ensure function
• Device deactivated by cycling to allow the pump to
fill partially & pushing the deactivation button
• Slight indentation should be felt in the pump to allow
for activation later
• Closure in layers with absorbable sutures
• Scrotal support given
• No drain
34. Post-op care
• PUC removed next morning
• Broad-spectrum antibiotics for 1-2wks after discharge
• AUS remains deactivated for average 4-6 weeks
• After activation patient may continue to have urgency
or develop de novo urgency
• Baseline X-ray
35.
36. Complications
• AUR → 12Fr Foley → TWOC after 48hr → SPC if fails
• Infections – 1-3% (upto 10% in radiation)
– S. aureus, S. epidermidis
– Salvage NOT in sepsis, ketoacidosis, pus, necrotising inf.
• Urethral Erosion – upto 5% → Implant removal
• Urethral Atrophy – Cuff movement / downsizing
• Mechanical failure – life expectancy of 7-10yr
– Any component fails after 3yr → Total replacement
