Artificial Urethral Sphincter Implantation Research Articles

143 - Exploration of the relationship between the results of Urethral pressure profilometry and the efficacy and complications of artificial urethral sphincter implantation: based on real-time intraoperative monitoring

143 - Exploration of the relationship between the results of Urethral pressure profilometry and the efficacy and complications of artificial urethral sphincter implantation: based on real-time intraoperative monitoring

Artificial urinary sphincter and stricture disease: surgical principles in management.

Iatrogenic stress urinary incontinence (SUI) is the most common complication of surgical treatment of prostate cancer, regardless of operative approach, and has a major impact on patients' quality of life. Although SUI can occur after surgical treatment of benign prostatic hyperplasia, specifically transurethral prostate resection, laser enucleation of the prostate, and simple open prostatectomy, these therapeutic modalities play a much less significant role in the etiology of SUI. Artificial urethral sphincter (AUS) implantation is considered the standard treatment modality providing high success rates, including durable efficacy, and optimal patient satisfaction for moderate to severe urinary incontinence resulting mainly from radical prostatectomy. However, although complication rates are generally acceptably low, revision and/or explantation may be required due to mechanical failure and non-mechanical problems, specifically urethral atrophy/cuff deficient occlusion, infection, and cuff erosion. Several risk factors for AUS failure associated with a fragile, compromised urethra have been identified and these play a critical role in device cuff erosion and subsequent removal of the device. Among others, apparently the most impacting factors are irradiation, urethral stent placement, a previous AUS placement, and importantly presence of urethral stricture or prior urethroplasty. Generally, any clinical situation leading to a diseased urethra or lack of urethral integrity is associated with impaired local blood perfusion, and consequently lower success rates. The present review aims to evaluate the impact of the presence of prior urethral strictures and urethroplasty on the outcomes of AUS implantation on one hand, and vice-versa, the influence of AUS placement on later urethral stricture surgery, particularly following cuff erosion.

Application of modified urethral separation method in artificial urethral sphincter implantation and its influence on intraoperative urethral pressure profilometry

Objective: To explore the application of modified urethral separation method in artificial urethral sphincter (AUS) implantation in patients with stress urinary incontinence (SUI), and its influence on the results of urethral pressure profilometry. Methods: A prospective collection of clinical data was conducted on 25 patients with stress urinary incontinence who underwent modified urethral separation method in AUS implantation and underwent urethral pressure profilometry in Beijing Hospital, Beijing Jishuitan Hospital Affiliated to Capital Medical University and the Second Hospital Affiliated to Tianjin Medical University from March 2019 to June 2023. The improved urethral separation method was to borrow part of the white membrane tissue of the cavernous body while freeing the dorsal side of the cavernous body of the urethra. The circumference of the urethra, sleeve size, and urethral pressure were recorded, the patient's autonomous urinary control before and after surgery and the changes of the international consultation on incontinence questionnaire-short form (ICI-Q-SF) score, incontinence quality of life questionnaire (I-QoL) score, urinary frequency score, nocturia score were compared. Follow-up was conducted in the clinic or by telephone at 1, 3, 6, and 12 months after activation of the device, and once a year thereafter. Local skin status and urine control were assessed, residual urine volume was measured by ultrasound and subjective score scale was completed. Results: All patients were male, aged 27-85 (65.8±15.7) years old. The circumference of the cuff used in this study was 4.0 cm in 4 patients (16.0%), 4.5 cm in 16 patients (64.0%), 5.0 cm in 4 patients (16.0%), and 5.5 cm in 1 patient (4.0%). Among them, the urethral circumference matched the cuff size in 14 cases (56.0%), the urethral circumference was smaller than the cuff size in 4 cases (16.0%), and the urethral circumference was larger than the cuff size in 7 cases (28.0%). Preoperative urodynamic examination showed that the maximum urethral pressure (MUP) was (78.0±25.9) cmH2O, (1 cmH2O=0.098 kPa) and the maximum urethral closure pressure (MUCP) was (53.4±26.6) cmH2O. The MUP of AUS device in the inactivated state was (88.0±26.5) cmH2O, which was not significantly higher than that before operation (P>0.05). The MUCP was (68.2±24.5) cmH2O, which was significantly higher than that before operation (P<0.05). The MUP and MUCP of the AUS device in the activated state were (146.6±25.2) cmH2O and (123.0±28.3) cmH2O, which were significantly higher than those before surgery and in the inactivated state (both P<0.001). All patients in the group reached the social urinary control standards at the first month of device activation. During a follow-up period of 2-50 months, 22 patients (88.0%) used the initial AUS device and all met social urinary control standards. The AUS device was replaced in 1 case. One patient died of cerebrovascular accident. One patient removed the device due to complications. The number of pads [M (Q1, Q3)] used in 25 patients before and after operation was 4.5 (3.0, 6.5) and 1 (0, 1) respectively, with statistically significant differences (P<0.001). ICI-Q-SF score, I-QoL score, urinary frequency score and nocturia score of 25 patients were significantly improved after surgery (all P<0.05). The incidence of postoperative complications was 20.0% (5/25), including 2 cases of painless hematuria, 1 case of infection, 1 case of urethral erosion, and 1 case of dysuria. Except for one patient who experienced urethral erosion and had his sleeve removed, the remaining four patients regained social urination control with active support treatment, and no symptoms recurred until the last follow-up. Conclusion: The modified urethral separation method has no significant effect on urethral pressure in patients with SUI, and can increase the volume of peri-urethral tissue in the cuff, thereby reducing the risk of intraoperative urethral injury and the incidence of postoperative urethral erosion.

Urethral management after artificial urinary sphincter explantation due to cuff erosion.

The artificial urethral sphincter (AUS) is the gold standard treatment in cases of moderate-to-severe stress urinary incontinence in males. Cuff erosions are one of the most important distant complications of AUS implantation. The optimal urethral management has still not been established. Search terms related to 'urethral stricture', 'artificial urinary sphincter', and 'cuff erosion' were used in the PubMed database to identify relevant articles. In this mini review we identified 6 original articles that assessed the urethral management after AUS explantation due to cuff erosion and included urinary diversion by transurethral and/or suprapubic catheterization, urethrorrhaphy, and in situ urethroplasty. We summarized the results of different management methods and their efficacy in terms of preventing urethral stricture formation. We highlight the need for better-quality evidence on this topic. The available data do not provide a clear answer to the question of optimal urethral management during AUS explantation. There is a great need to provide higher-quality evidence on this topic.

Satisfaction with Urinary Incontinence Treatments in Patients with Chronic Spinal Cord Injury.

Purpose: To investigate the long-term satisfaction and complications in chronic spinal cord injury (SCI) patients after various bladder management strategies and surgical procedures for the treatment of urinary incontinence. Methods: Patients at a single institution with chronic SCI who received bladder management treatment or surgical procedure to improve urinary continence were retrospectively assessed. Thorough urological examinations and videourodynamic studies were performed. Patients were treated either through conservative approaches including medical treatment, clean intermittent catheterization (CIC), cystostomy, and indwelling urethral catheter, or through surgical procedures including detrusor botulinum toxin (Botox) injections, augmentation, ileal conduit, Kock pouch diversion, continent cystostomy, suburethral sling, and artificial urethral sphincter (AUS) implantation. The patients’ satisfaction with urinary continence improvement, causes of dissatisfaction, long-term complications, and overall satisfaction with bladder and voiding condition were assessed. Results: A total of 700 consecutive patients were enrolled in this study. High satisfaction rates were noted after detrusor Botox injection (81.1%), augmentation enterocystoplasty (91.4%), autoaugmentation (80%), Kock pouch diversion, and continent cystostomy (all 100%). Fair satisfaction rates were noted after ileal conduit diversion (66.7%), suburethral sling (64.3%), and AUS implantation (66.7%). Patients who received conservative treatment with medicines, CIC, cystostomy, or an indwelling urethral catheter all had less-satisfactory outcomes (all < 40%). Conclusion: Overall satisfaction with surgical procedures aimed to improve urinary continence in chronic SCI patients was higher than with conservative bladder management (35.4%). Appropriate surgical procedures for chronic SCI patients with neurogenic lower urinary tract dysfunction (NLUTD) and urological complications yielded satisfaction with both urinary continence improvement and with overall bladder and voiding condition.

Intraurethral catheter placement does not change the external circumferential measurement of the urethra during AUS placement: A prospective observational trial.

Measuring the urethral circumference accurately during artificial urethral sphincter (AUS)placement is an important technical aspect to optimize the selection of cuff size. Differing methods exist for this step with some experts recommending measurement with no urethral catheter in place. In this prospective observational trial, we compared urethral measurements with and without an indwelling catheter to determine if the presence of a catheter affects the circumferential measurement. With IRB approval, we prospectively collected data on consecutive cases of transperineal male AUS implantation. Urethral circumference was measured with no urethral catheter (0 French [Fr]), 12Fr, and 16Fr Foley catheters in the urethra. The final measurements and cuff size chosen were recorded. A comparison was made between each measurement using Spearman's correlation coefficient. A total of 54 patients were included, the majority of whom (92.6%) underwent AUS placement for postprostatectomy incontinence. The three urethral circumference measurements were highly correlated (0Fr vs 12Fr, ρ = 0.96, P < .001, mean difference 1 mm) (0Fr vs 16Fr, ρ = 0.94, P < .001, mean difference 2 mm) (12Fr vs 16Fr, ρ = 0.96, P < .001, mean difference 1 mm). Patients with a history of radiation had a lower mean urethral circumference than those who had never been radiated (4.78 cm vs 5.3 cm, P = .01). Urethral circumference measurement during AUS implantation is not influenced by the presence of a 12 or 16Fr Foley catheter when compared to no catheter in the urethra. Measurement of the urethral circumference can, therefore, be accurately performed with or without a catheter in place, depending on the surgeon's preference.

Urethral pressure profilometry in artificial urinary sphincter implantation: A case report

BACKGROUNDArtificial urethral sphincter (AUS) implantation is currently the gold standard for treating moderate and severe urinary incontinence. Currently, cuffs are chosen based on the surgeon’s experience, and adjusting cuff tightness is crucial. The T-DOC air-charged catheter has not been proven to be inferior to traditional catheters. We report how intraoperative urethral pressure profilometry is performed using a T-DOC air-charged catheter with ambulatory urodynamic equipment, to guide cuff selection and adjustment.CASE SUMMARYA 67-year-old man presented to our hospital with complete urinary incontinence following transurethral prostatectomy, using five pads/d to maintain local dryness. Preoperatively, the maximum urethral pressure (MUP) and maximum urethral closure pressure (MUCP) were 52 cmH2O and 17 cmH2O, respectively. An AUS was implanted. Intraoperatively, in the inactivated state, the MUP and MUCP were 53 cmH2O and 50 cmH2O, respectively; in the activated state, they were 112 cmH2O and 109 cmH2O, respectively. The pump was activated 6 wk postoperatively. Re-measurement of the urethral pressure on the same day showed that in the inactivated state, MUP and MUCP were 89 cmH2O and 51 cmH2O, respectively, and in the activated state, 120 cmH2O and 92 cmH2O, respectively. One month after device activation, telephonic follow-up revealed that pad use had decreased from five pads/d to one pad/d, which met the standard for social continence (0-1 pad per day). There were no complications.CONCLUSIONThe relationship between intraoperative urethral pressure and urinary continence post-surgery can provide data for standardizing AUS implantation and evaluating efficacy.

Post Prostatectomy Vesicourethral Stenosis or Bladder Neck Contracture with Concomitant Urinary Incontinence: Our Experience and Recommendations

Objectives: To present our experience in the management of bladder neck contracture with concomitant post prostatectomy incontinence and to provide our recommendations based on the updated literature. Materials and Methods: Between Jan 2010 and June 2015, 37 patients from our cohort of 341 patients with post prostatectomy incontinence were evaluated. Patient data were retrospectively collected. Patients with bladder neck contracture confirmed on flexible cystoscopy underwent subsequent rigid cystoscopy and deep endoscopic bladder neck incision (BNI). A follow up flexible cystoscopy would be performed 3 months later. If there was no recurrence of the bladder neck contracture, an artificial urethral sphincter (AUS) or a male sling was recommended. Results: The mean age of patients was 68 years (range 59-77) and the mean BMI was 31 (range 21-41) kg/m². Twenty-five (67.7%) patients had open prostatectomy and 12 (32.4%) patients had laparoscopic prostatectomy. Fourteen patients (37.8%) underwent adjuvant radiotherapy. Twenty-four (64.8%) patients had one BNI procedure, 8 (21.6%) patients had two procedures and 5 (13.5%) patients had more than 2 procedures. Twenty-one (91.3%) patients had AUS implantation and 2 (8.7%) patients had male sling placement. Besides, 85.7% of AUS and 50% of male sling patients managed to achieve successful outcomes with a mean follow up period of 13.1 months ( range 2-33 months). Conclusion: Initial management with aggressive BNI followed by implantation of an AUS or male sling when bladder neck is stable is essential to achieve a satisfactory urinary continence outcome.

Male Readjustable Sling (MRS) System for Postprostatectomy Incontinence: Experiences of 2 Centers

To evaluate the outcomes of Male Readjustable Sling (MRS) in patients with postprostatectomy incontinence at 2 unrelated centers and to determine preoperative factors relevant to the outcome. From January 2007 to January 2014, a total of 64 men with urinary incontinence following radical prostatectomy were treated with MRS at 2 centers. Patients were evaluated based on medical history, daily pad usage, urodynamics, and cystoscopy. The clinical outcome was evaluated according to daily pad usage and questionnaires. Success was defined according to reductions in the number of pads used per day after surgery, and factors related to surgical outcome were investigated. The median age of the patients was 70 years (range: 53-84), and the mean follow-up duration was 46.0 ± 19.47 months (range: 12-89). During follow-up, readjustment of the sling was required 1.9 times on average. Daily pad usage decreased significantly from 3.42 ± 2.00 to 0.84 ± 1.20 (P <.001), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score improved (18.65 ± 2.61 to 10.55 ± 6.21, P <.001) without deterioration of voiding symptoms at the last follow-up. MRS was successful in 46 of 64 patients (71.9%). Of the 18 patients who experienced surgical failure, 12 patients required secondary artificial urethral sphincter implantation. The number of daily used pads (odds ratio 1.414) and a history of pelvic irradiation (odds ratio 8.400) were potential risk factors for surgical failure. According to our midterm follow-up data, MRS is an effective and a safe treatment option for radiation-naïve patients with a mild degree of postprostatectomy incontinence.

Surgery for stress urinary incontinence due to presumed sphincter deficiency after prostate surgery.

Incontinence after prostatectomy for benign or malignant disease is a well-known and often a feared outcome. Although small degrees of incidental incontinence may go virtually unnoticed, larger degrees of incontinence can have a major impact on a man's quality of life.Conceptually, post-prostatectomy incontinence may be caused by sphincter malfunction or bladder dysfunction, or both. Most men with post-prostatectomy incontinence (60% to 100%) have stress urinary incontinence, which is involuntary urinary leakage on effort or exertion, or on sneezing or coughing. This may be due to intrinsic sphincter deficiency and may be treated with surgery for optimal management of incontinence. Detrusor dysfunction is more common after surgery for benign prostatic disease. To determine the effects of surgical treatment for urinary incontinence related to presumed sphincter deficiency after prostate surgery for:- men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) - transurethral resection of prostate (TURP), photo vaporisation of the prostate, laser enucleation of the prostate or open prostatectomy - and- men with prostate cancer - radical prostatectomy (retropubic, perineal, laparoscopic, or robotic). We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, and handsearching of journals and conference proceedings (searched 31 March 2014); MEDLINE (January 1966 to April 2014); EMBASE (January 1988 to April 2014); and LILACS (January 1982 to April 2014). We handsearched the reference lists of relevant articles and conference proceedings. We contacted investigators to locate studies. Randomised or quasi-randomised trials that include surgical treatments of urinary incontinence after prostate surgery. Two authors independently screened the trials identified, appraised quality of papers, and extracted data. Only one study with 45 participants met the inclusion criteria. Men were divided in two sub-groups (minimal or total incontinence) and each group was randomised to artificial urethral sphincter (AUS) implantation or Macroplastique injection. Follow-up ranged from six to 120 months. In the trial as a whole, the men treated with AUS were more likely to be dry (18/20, 82%) than those who had the injectable treatment (11/23, 46%) (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.28 to 25.10). However, this effect was only statistically significant for the men with more severe ('total') incontinence (OR 8.89, 95% CI 1.40 to 56.57) and the CIs were wide. There were more severe complications in the group undergoing AUS, and the costs were higher. AUS implantation was complicated in 5/22 (23%) men: the implant had to be removed from one man because of infection and in one man due to the erosion of the cuff, in one man the pump was changed due to mechanical failure, in one man there was migration to the intraperitoneal region, and one man experienced scrotal erosion. In the injectable group, 3/23 (13%) men had a complication: one man treated with Macroplastique injection had to be catheterised because of urinary retention and two men developed urinary tract infections. The evidence available at present was of very low quality because we identified only one small randomised clinical trial. Although the result was favourable for the implantation of AUS in the group with severe incontinence, this result should be considered with caution due to the small sample size and uncertain methodological quality of the study found.

High revision rate following artificial urethral sphincter implantation

Objective. In severe cases of stress urinary incontinence (SUI), with sphincter dysfunction, the artificial urinary sphincter AMS 800™ may be the last solution. The purpose of this study was to evaluate the outcome of surgical intervention for SUI with the AMS 800 in patients who were treated at Sahlgrenska University Hospital, Gothenburg. The primary aim of the study was to determine the complications related to the operation. Material and methods. A retrospective follow-up was done by reviewing medical records. The material comprised 97 men, who underwent their first AMS 800 implantation between May 1997 and June 2010 at Sahlgrenska University Hospital. Results. The revision rate was 28%, including an infection rate of 3% and an erosion rate of 7%. The mean follow-up for revised patients was 3 years. The median time until revision was 1 year. Seventy-five per cent of all patients were satisfied with the operation at 6 months’ follow-up. Radical prostatectomy was the reason behind incontinence in 84% of patients in this series. Conclusion. The results clearly demonstrate a need for revision procedures in a considerable proportion of patients implanted with an AMS 800 device. Patient satisfaction was high, but although this operation has extremely low mortality it has its complications and the system will need to be replaced in time.

URINARY INCONTINENCE Psychological aspect of qualification to implant an artificial urethral sphincter AMS 800

IntroductionImplantation of the AMS 800 artificial urethral sphincter is a “gold standard” in the treatment of total urinary incontinence in men. Appropriate qualification of patients to urinary incontinence treatment determines the higher effectiveness of this method. Service of this device requires physical fitness and mental efficiency from a patient.Material and methodsThe Urological Clinic hospitalized 16 patients, aged from 60 to 80 years, after first qualification for artificial urethral sphincter implantation. Psychological assessment was carried out during anamnesis and medical examination using the MMSE and the GDS.ResultsPsychological deviations were found in 7 out of 16 examined patients, but finally 2 patients were disqualified because of their cognitive function disorders with elements of low level depressive syndrome (1) and benign cognitive and member function disorders (1). Among the patients who were examined by a psychologist: four of them showed mild (3) and temperate (1) features of depressive syndrome and one patient showed benign cognitive disorder without dementia. However, none of these findings were contraindications to incontinence treatment with an artificial urethral sphincter.Conclusions1. Mild and temperate features of depression syndrome are not absolute contraindications for a sphincter AMS 800 implantation. These patients need only pharmacological treatment. 2. Cognitive and other memory disorders are contraindications to this method. 3. The qualification to implantation an artificial urethral sphincter should include a psychological assessment, especially in older patients in whom mental disorders are suspected.

Comparison between Two Different Two-Stage Transperineal Approaches to Treat Urethral Strictures or Bladder Neck Contracture Associated with Severe Urinary Incontinence that Occurred after Pelvic Surgery: Report of Our Experience

Introduction. The recurrence of urethral/bladder neck stricture after multiple endoscopic procedures is a rare complication that can follow prostatic surgery and its treatment is still controversial. Material and Methods. We retrospectively analyzed our data on 17 patients, operated between September 2001 and January 2010, who presented severe urinary incontinence and urethral/bladder neck stricture after prostatic surgery and failure of at least four conservative endoscopic treatments. Six patients underwent a transperineal urethrovesical anastomosis and 11 patients a combined transperineal suprapubical (endoscopic) urethrovesical anastomosis. After six months the patients that presented complete incontinence and no urethral stricture underwent the implantation of an artificial urethral sphincter (AUS). Results. After six months 16 patients were completely incontinent and presented a patent, stable lumen, so that they underwent an AUS implantation. With a mean followup of 50.5 months, 14 patients are perfectly continent with no postvoid residual urine. Conclusions. Two-stage procedures are safe techniques to treat these challenging cases. In our opinion, these cases could be managed with a transperineal approach in patients who present a perfect operative field; on the contrary, in more difficult cases, it would be preferable to use the other technique, with a combined transperineal suprapubical access, to perform a pull-through procedure.

Complications rates of non-oncologic urologic procedures in population-based data: a comparison to published series

Published single institutional case series are often performed by one or more surgeons with considerable expertise in specific procedures. The reported incidence of complications in these series may not accurately reflect community-based practice. We sought to compare complication and mortality rates following urologic procedures derived from population-based data to those of published single-institutional case series. In-hospital mortality and complications of common urologic procedures (percutaneous nephrostomy, ureteropelvic junction obstruction repair, ureteroneocystostomy, urethral repair, artificial urethral sphincter implantation, urethral suspension, transurethral resection of the prostate, and penile prosthesis implantation) reported in the U.S.'s National Inpatient Sample of the Healthcare Cost and Utilization Project were identified. Rates were then compared to those of published single-institution series using statistical analysis. For 7 of the 8 procedures examined, there was no significant difference in rates of complication or mortality between published studies and our population-based data. However, for percutaneous nephrostomy, two published single-center series had significantly lower mortality rates (p < 0.001). The overall rate of complications in the population-based data was higher than published single or select multi-institutional data for percutaneous nephrostomy performed for urinary obstruction (p < 0.001). If one assumes that administrative data does not suffer from under reporting of complications then for some common urological procedures, complication rates between population-based data and published case series seem comparable. Endorsement of mandatory collection of clinical outcomes is likely the best way to appropriately counsel patients about the risks of these common urologic procedures.

1608 DECOMPENSATION OF AMS 800 RESERVOIR ELASTICITY AS A MECHANISM FOR GRADUAL ARTIFICIAL URETHRAL SPHINCTER FAILURE: A CASE SERIES DEMONSTRATING NOVEL EVALUATION AND TREATMENT WITH RESERVOIR REPLACEMENT ALONE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy II1 Apr 20101608 DECOMPENSATION OF AMS 800 RESERVOIR ELASTICITY AS A MECHANISM FOR GRADUAL ARTIFICIAL URETHRAL SPHINCTER FAILURE: A CASE SERIES DEMONSTRATING NOVEL EVALUATION AND TREATMENT WITH RESERVOIR REPLACEMENT ALONE Phillip Pierorazio and Jacek Mostwin Phillip PierorazioPhillip Pierorazio More articles by this author and Jacek MostwinJacek Mostwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1386AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Progressive deterioration of urinary continence after artificial urethral sphincter implantation occurs in 3 to 9% of patients. The most common etiology is believed to be urethral atrophy with recommended treatment including replacement or doubling of the urethral cuff with or without replacement of other components. We have identified a previously unrecognized mechanism: reduced reservoir elasticity. METHODS Nine patients operated on by a single surgeon were noted to have mechanical failure of the artificial sphincter reservoir. All patients described a gradual reduction of continence with increasing need for absorbent protection. Pre-operative cystoscopy excluded erosion; plain x-rays showed contrast in the system. At re-exploration, mechanical failure was investigated using standard arterial catheter pressure sensors provided with anesthesia machines. If pressure readings below manufacturer's specifications were noted, the reservoir alone was replaced; the perineum and cuff were left intact. Reservoirs were returned to the manufacturer for evaluation. Patient outcomes were self-reported to the surgeon. RESULTS Median age at initial artificial sphincter implantation was 61 yrs (52 - 75); average time to revision was eight yrs (3 to 13). At initial implantation, all patients received 4.5 cm cuffs; all but one had 61-70 cmH2O reservoirs, and one had a 71-80 cmH2O reservoir. The mean reservoir pressure in situ at re-exploration was 36 mmHg (27 – 41mmHg). Converted to cmH2O, the pressures were 50.4 cmH2O (37.8-57.4). The mean volume was 27 cm3 (25 - 30) which is higher than the standard volume of 20 cm3. In each case, the reservoir pressure was less than the nominal pressure range. Evaluation by the manufacturer revealed appearance and behavior consistent with the duration of implant. In all patients the artificial sphincter reservoir was replaced through the initial inguinal incision. All patients had complete restoration of urinary continence; one patient eventually required cuff revision due to subsequent erosion. CONCLUSIONS In the subset of patients with gradual and progressive incontinence following artificial sphincter implantation, reduced reservoir pressure can be investigated and confirmed intra-operatively. If abnormal, the reservoir can be replaced through a very limited operation, restoring urinary control without replacement or revision of the urethral cuff. Baltimore, MD© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e621 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Phillip Pierorazio More articles by this author Jacek Mostwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Three-dimensional MRI of the male urethrae with implanted artificial sphincters: initial results

The aim of this study was to develop a method for simultaneous 3D visualization of a new type of artificial urethral sphincter (AUS) and adjacent urinary structures. Serial MR tomograms were acquired from seven men after AUS implantation. 3D reconstruction was performed by thresholding original (positive) and inverted (negative) image intensity and by subsequently fusing positive and negative images. Results show that the bladder, cuff and balloons of the AUS of originally high intensity were imaged in 3D by thresholding the positive datasets. The urethrae and corpora cavernosa penis of originally low intensity were displayed in 3D by thresholding the negative datasets. Fusion of the positive and negative datasets allowed simultaneous visualization of the AUS complex and adjacent urinary structures. All the structures of interest were also clearly seen by interactive multiplanar reformatting. Coronal tomographic datasets provided better 3D and reformatted 2D images than sagittal and transverse datasets. This technique offers a simple means for evaluating the complex urethral anatomy and the AUS, and has potential for improved 3D visualization of many other complex morphological and pathological conditions.

THE SIGNIFICANCE OF THE OPEN BLADDER NECK ASSOCIATED WITH PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS

As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

THE SIGNIFICANCE OF THE OPEN BLADDER NECK ASSOCIATED WITH PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS

Purpose As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. Materials and Methods We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. Results Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. Conclusions Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.