Download - Artificial Urinary Sphincter Case Report

8/12/2019 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