Artificial Urinary Sphincter Case Report

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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