ARTIFICIAL URINARY SPHINCTER

ARTIFICIAL URINARY SPHINCTER
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

Urinary incontinence (UI)
• The complaint of any involuntary leakage of
urine
• Causes
– Congenital anomalies
– Injury
– Genitourinary surgery
– Miscellaneous causes
3
Dept of Urology, GRH and KMC, Chennai.

• Urinary continence in the male depends on
– A compliant and contractile bladder body
– Functional posterior urethra
• The bladder neck
• Intact prostatic (internal sphincter) sphincter
• Intact rhabdosphincter (external sphincter)
4

• Internal sphincter incompetence causes
– Pelvic surgery
– Bladder neck injury
– Specific sympathetic neuropathic dysfunction
– Embryologic disruption
• Incompetence of the external sphincter, known as intrinsic
sphincter deficiency (ISD), causes
– Radical prostatectomy (most frequent)
– Prostatomembranous urethral distraction injuries,
– Traumatic and acquired myelopathy
– Spinal dysraphism
– Sacral agenesis
– Exstrophy/Epispadias complex.
5

• Incontinence after TURP
– Reflect persistent bladder overactivity
– Rarely results from damage to the external sphincter
during transurethral resection
• Incidence of incontinence after Radical
Prostatectomy is 2.5% to 87%
• Progressive improvement in urinary control
occurs
• Nerve-sparing techniques pioneered by Walsh
decreases rate of urinary incontinence 6

To be ruled out
• Associated bladder dysfunction
– Decreased compliance
– Detrusor overactivity
7

• Radical prostatectomy (RP) the most common
etiology of Sphincteric UI in men
8

9

OPTIONS FOR URINARY
INCONTINENECE
• Surgical treatment
– Including transurethral bulking agents
– Bulbar urethral slings
– The artificial urinary sphincter (AUS)
10

Bulking Agents Vs AUS
• Bulking agents were first-line treatment for male
sphincteric UI
• Poor results in
– Severe incontinence
– Patients with Postprostatectomy scarring in the
vesicourethral region
• The AUS - The gold standard for the treatment of
UI
– Has long-term durability
– Is highly Efficient
– Is a solution to moderate and severe degrees of
urinary loss.
11

Sling VS AUS
Sling AUS
• Appropriate for treatment of mild to
moderate incontinence
• 70-85% success rates
• 45-60± minute outpatient procedure
• Transient scrotal/penile and perineal
pain
• Passive
• Favorable data (durability?)
• Complications
• Infection and Erosion ( < 2%)
• Reoperation rate (unknown?)
• The Gold Standard for treatment
of moderate to severe
incontinence (85-95% success)
• 60± minute outpatient procedure
• Catheter for 23 hours
• Transient scrotal/penile and perineal
pain
• “Active”
• Over 30 year track record of durability
• Complications
• Infection and Erosion (5-10%)
• Approx 15% require revision
surgery over a 10-15 year period 12

INDICATIONS FOR SURGERY
• Patients with irreversible intrinsic sphincter
deficiency
• Bothersome involuntary leakage of urine
• Severe or gravitational UI after radical
prostatectomy showing no improvement in 6
monts
13

Post prostatectomy
incontinence showing
incomplete
circumferential
coaptation of the
sphincter
14

Absolute contraindications
• Bladder disorders that jeopardize renal
function
– Diminished vesical compliance and
– Vesicoureteral reflux at low intravesical pressure
• Inadequate tissue integrity at the bladder
neck or urethra to accommodate AUS
(may require bladder neck closure or urinary
diversion)
15

Relative contra indications
• Urinary tract abnormalities that require future
transurethral management
– Bladder cancer
– Refractory vesicourethral anastomotic strictures
16

History
• In 1976, Rosen designed the first model of an
AUS
• In 1978, Scott presented his initial report with
the AMS 721 with 79% success rate
• In 1988, The AMS 742 allowed automatic cuff
closure after cuff decompression
• In 1989, The AMS 791 and 792 used a silicone
rubber cuff and a deactivation button
• The AMS 800 included the deactivation button
within the control pump
17

Early models
18

Artificial FlowSecureTM
urinary
sphincter
(1)a pressure-regulating
balloon
(2)a stress relief balloon
(3)a control pump
(4)a cuff
19

AMS 800
20

AMS 800 with tandem cuff
21

Preoperative evaluation
• Detailed history
• Physical examination
• Urinalysis
• Cystoscopy
• Pressure flow urodynamics
22

Medical history
• Focus on the type, degree, and severity of UI
• H/o Previous surgical procedures
• Symptoms of neurologic disease
• Specific evaluation of the failed AUS
23

• Differentiation between stress and urge UI
– Voiding diary
– Pad test
24

Physical examination
• Thorough examination
– Abdomen
– Back
– Genitalia
– Perineum
– Rectum
– Neurologic system
25

Physical examination
• Status of the skin examined for
– Integrity
– Infection (eg: fungal)
– Incision (of previous procedure)
• Inguinal hernias, hydroceles and scrotal
masses should be looked for
26

Laboratory investigations
• Complete Urine analysis
• Urine culture and sensitivity
• Renal function test
• Serum PSA (especially in post radical
prostatectomy)
27

Cystoscopy
• To rule out
– Vesicourethral anastomotic stricture
– Bladder neck contracture
– Bulbar urethral stricture
• In cases of previous failed AUS, urethral
atrophy should be ruled out before
reimplantation
28

Urodynamics
• To assess
– Bladder capacity
– Compliance
– Contractility
• To rule out bladder pathology that might
cause persistence of symptoms after the
procedure
29

SPECIAL SITUATION: Evaluation of Persistent
Incontinence after AUS
• Aim : To differentiate between
– Inadvertent deactivation
– Insufficient urethral compression (oversizing of
cuff)
– Mechanical failure with fluid loss
– Cuff erosion
– Bladder storage failure
– Urethral or bladder neck atrophy under the cuff
– Plugged delay-fill resistor or kinked tubing (rare)
30

AMS 800
31

AMS 800
A fluid-filled cuff Placed around
the bladder neck or
bulbar urethra
Control pump Placed in the
scrotum
Pressure-regulating
balloon (PRB)
Placed in a
preperitoneal
or intraperitoneal
location 32

33

PROCEDURE
• Skin, Colles fascia incised
• Bulbospongiosus muscle, Buck fascia is incised
over the convergence of corporal bodies
34

35

Placement of
the cuff
The preferred location is
proximal to the
convergence of corporal
bodies
36

-Bulbospongiosus divided
-Corpus spongiosus exposed
37

Interface between
spongiosum and right
crus of the
cavernosum dissected
38

Circumferential
dissection and Right-
angle clamp behind
corpus spongiosum
39

Placement
of the cuff
40

Technical aspects
• Circumference of urethra should be measured
and appropriate size of cuff selected
• The Foley should be removed before the
measurement
• The best test of cuff fit is the visual and
endoscopic appearance
41

Endoscopic
appearance
of cuff in-stu
42

Control pump placement
• Another small scrotal incision made
• Tunnelled to the perineal incision
• A subdartos pouch created
• Pump kept in the pouch
43

Placement of
pump in the
subdartos
pouch
44

Pressure-Regulating Balloon (PRB)
placement
Scrotal, perineal, or abdominal incision made
based on the expertise of surgeon
• Abdominal incision
– Rectus split
– The preperitoneal space accessed
– Digital dissection creates the space required for
the PRB
45

46

Tandem cuff
47

COMPLICATIONS
48

Urinary Retention
• Acute retention
– Ensure Cuff deactivation
– Transurethral bladder drainage with a small (10-Fr or
12-Fr) catheter for 24 to 48 hours
• Retention >48 hrs has erosion risk
– Suprapubic diversion to be done
– Use ultrasound or fluoro to guide the puncture
without injuring the implant
• Retention beyond several weeks means ‘over cuff
size’
– Undersizing the cuff
– Rule out proximal urethral obstruction
49

Urinary Retention
• Late-onset urinary retention
– Endoscopic evaluation
– Urodynamic evaluation
• Causes
– Erosion
– Undiagnosed Proximal urethral obstruction
– Undiagnosed Detrusor failure
50

AUS Infection
• A serious and devastating complication
• Rate is 1% to 3%
– 10% in cases of pelvic irradiation & reoperations
• Skin pathogens are the most common organisms
– Staphylococcus epidermidis &
– S. aureus
• Late infections (>4 months) are due to indolent
organinsms introduced by haematogenous route
• All men undergoing AUS implant should be given
prophylactic antibiotics as per AUA guidelines
51

AUS Infection
• Clinical presentation:
– Persistent fever in the postoperative period
– Scrotal pain
– Erythema
– Edema
– Frank purulence
• Management:
– Explantation
– Removal of device →antiseptic
irrigation→reimplantation→continuing irrigation
regime
52

AUS Infection
• Contraindications to prosthesis salvage
– Sepsis
– Ketoacidosis
– Necrotizing infection
– Immunosuppression
– Presence of gross purulent material
53

Urethral Erosion
• Incidence is 5%
• Risk factors:
– Hypertension
– Coronary artery disease
– Prior radiation therapy
– Prior AUS revisions
• Prevention:
– Postoperatively deactivation of the pump till the
healing process is complete (decreases the chance
from 18% to 1.3%)
54

Urethral Erosion - management
• Immediate removal of all the components of
the AUS
• SPC or urethral catheter drainage (if possible)
• Reimplantation may be possible after 6
months if urethrography confirms healing
55

Urethral Atrophy
• Most common reason for revision of the AUS
• Results from the chronic compression of the
spongy tissue under the occlusive cuff
• Treatment options
– Cuff downsizing
– Movement of the cuff proximally or distally where
the urethra may be thicker
– Placement of a second cuff in tandem.
56

THANKYOU
57

ARTIFICIAL URINARY SPHINCTER

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