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Artificial Urinary
Sphincter: Techniques
and Complications
Case Seen By: Dr. Niall Heney, M.D.Dr. Boris Gershman, M.D.
Department of Urology, Massachusetts General HospitalHarvard Medical School
Case Presented by: Aaron Desai, Medical Student
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HPI
A 41 yo male with a history of Spinabifida/myelomeningocele and bladder augmentationpresented with urinary incontinence
s/p placement of artificial urinary sphincter x 2.
Describes as life changing urinary incontinence x 6months.
Continues to be significantly incontinent though doesurinate approximately 3-4 times on a daily basis butdoes leak in between voids.
ROS: as above
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Past Medical/Surgical
History Spina bifida/myelomeningocele/hydrocephalus
Bladder augmentation-? ureteral reimplantation
Artificial Urinary sphincter at bladder neck x 2. Firstdone in 1996 and replaced in 2002.
Kidney Stones
Scoliosis surgery- 3 rods in back 1980s
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Physical Examination
Middle aged man, overweight, wheelchair bound
He has significant Scoliosis
Anterior rotation of Pelvis Oriented x 3
Remaining Examination: Unremarkable
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Studies
CT Scan:
ShowedNo fluid in the reservoir
Cystoscopy
Showed no erosion of the urethra
No evidence of sphincter cuff compression of
urethra
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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 urethrathrough 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 forproper healing without erosion.
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Box
indicates
appropriate
location of
AUS cuff
Transscrotal
Approach
Perineal ApproachTandem Cuff AUS
Pump in Scrotum
AUS
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Bladder Neck AUS
Indication:
Men with sphincteric UI in whom the prostate is without externalsurgical 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), higherPRB pressure (usually 71 to 80 cm H2O),and a larger fluid volumein the system.
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Complications (continued)
Urethral Erosion:
Delayed deactivation has lowered the risk of erosion
Immediate removalof all the components as they are assumed to beinfected.
Re-implantationconsidered: after urethral healing is confirmed and adelay 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 occlusivecuff.
Most common reason for revision of the AUS.
Treatment: cuff downsizing, movement of the cuff to a more proximalor distal location, or placement of a second cuff in tandem.
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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 intra-
operatively, and, if in doubt, total device replacement is prudent
Devices greater than 3 years old should be replaced in
to to .
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Thank You