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Surgical Procedures for Sphincteric Incontinence in the Male

The Artificial Urinary Sphincter and Perineal Sling

Procedures

Hunter Wessells; Andrew Peterson

Questions

1.Which of the following is associated with a reduction in risk of artificial urinary sphincter (AUS) erosion?

a.Transscrotal approach

b.Proximal bulbar location

c.Narrow back modification

d.Inhibizone treatment

e.Cuff placement over bulbospongiosus muscle

2.The most significant contraindication to AUS for sphincteric incontinence is:

a.impaired cognitive function.

b.pad weight test result > 1000 mg/24 h.

c.prior pelvic irradiation.

d.detrusor overactivity.

e.organic erectile dysfunction.

3.The most likely cause of gradual return of urinary incontinence (UI) 2 years after AUS is:

a.mechanical failure.

b.subcuff urethral atrophy.

c.pressure-regulating balloon aneurysm.

d.new onset detrusor overactivity.

e.tubing kink.

4.A 54-year-old man with gravitational incontinence has a history of pelvic fracture urethral injury. Videourodynamics show mild detrusor overactivity and an open bladder neck. The best surgical treatment is:

a.transurethral bulking agent.

b.transobturator male sling.

c.bone-anchored male sling.

d.artificial urinary sphincter.

e.catheterizable continent stoma.

5.In a man with a history of recurrent noninvasive bladder cancer and sphincteric urinary incontinence following transurethral resection of the prostate (TURP) with a pad weight of 230 g for 24 hours and leak-point pressure of 80 cm H2O, the best solution for the incontinence is:

a.bulbar AUS.

b.bladder neck AUS.

c.Cunningham clamp.

d.transobturator male sling.

e.cystectomy and urinary diversion.

6.During urethral dissection for implantation of a bulbar artificial urinary sphincter, a urethrotomy is made with the scissors. After repairing the urethral defect, the next step is:

a.catheter drainage for 7 days and delayed replantation.

b.placement of the cuff at a more distal location.

c.transobturator sling placement.

d.irrigation with antibiotic solution and transcorporeal cuff placement.

e.tunica vaginalis flap coverage and bulbar cuff placement.

7.Efficacy of transobturator male sling post radical prostatectomy (RP) is reduced by prior:

a.collagen injection.

b.adjuvant radiation therapy.

c.transurethral resection of the prostate.

d.incision of bladder neck contracture.

e.penile prosthesis.

8.The most likely urodynamic finding in men with incontinence after RP is:

a.detrusor overactivity.

b.impaired detrusor contractility.

c.intrinsic sphincter deficiency.

d.sensory urgency.

e.detrusor hypocontractility.

9.A 59-year-old man develops a dense vesicourethral anastomotic stricture 2 years after bulbar AUS placement for post-RP UI. The best approach for treatment is:

a.dilation with sounds.

b.transurethral incision with Collins knife.

c.laser incision with flexible ureteroscope.

d.antegrade transurethral incision via suprapubic cystostomy.

e.open cuff exploration with transurethral incision after cuff uncoupling.

. A 43-year-old man with myelomeningocele has persistent incontinence after placement of a 4.0 cm bulbar artificial urinary sphincter. Urodynamics show Valsalva leak-point pressure (VLPP) of 55 cm H2O and normal bladder

capacity. The next step is:

a.downsize the cuff to 3.5 cm.

b.addition of tandem cuff.

c.reposition cuff at the bladder neck.

d.increase pressure-regulating balloon (PRB) to 71 to 80 cm H2O.

e.close bladder neck and create Mitrofanoff.

.The most important technical difference in implantation of a bladder neck versus bulbar AUS is:

a.cuff measurement.

b.location of PRB.

c.preperitoneal connections.

d.choice of PRB.

e.fluid volume in device.

.The factors most likely to predict new overactive bladder symptoms after artificial urinary sphincter placement include:

a.preoperative outlet procedure.

b.VLPP less than 60 cm H2O.

c.history of pelvic radiation.

d.cystometric capacity of 200 mL or less.

e.history of prior bladder neck contracture/stricture surgery.

.All of the following factors are associated with an increased risk of cuff erosion of an AUS EXCEPT:

a.prior explanation for erosion.

b.prolonged catheterization.

c.prior transobturator sling surgery.

d.history of pelvic radiation.

e.history of hypertension.

.In addition to a chief complaint and history of urinary leakage, prior to embarking on surgical therapy in the man with post-prostatectomy stress incontinence, the absolutely required evaluations include:

a.urodynamics.

b.voiding diary.

c.visual demonstration of stress incontinence with stress maneuvers.

d.pad weight test.

e.cystoscopy.

.The most common pathogen involved in a primarily infected artificial sphincter is:

a.Enterococcus.

b.Staphylococcus aureus.

c.Staphylococcus epidermidis.

d.Escherichia coli.

e.Candida.

.A 65-year-old male presents with stress incontinence after radical prostatectomy for Gleason 7 prostate cancer (pT3A). He has a history of adjuvant radiation therapy. He leaks urine with activity and when standing, has no urge component, and pad weight is 1200 mL per 24 hours. The most appropriate definitive therapy for his incontinence is:

a.quadratic male sling.

b.transobturator male sling.

c.AUS with bulbar placement.

d.AUS with transcorporeal placement.

e.urinary diversion.

Answers

1.c. Narrow back modification. The narrow back modification was associated with a reduced risk of erosion. Transscrotal approach may not achieve as proximal a location of the cuff, but this is associated with potential risk of worse incontinence, not erosion. Inhibizone treatment has no literature to support its value in the prevention of erosion. Preservation of the bulbospongiosus muscle has not been shown to affect erosion rates.

2.a. Impaired cognitive function. Significant cognitive impairment puts a patient at risk for inability to safely use an AUS. Radiation therapy and prior urethral surgery are relative contraindications to sling surgery because of reduced efficacy, perhaps due to poor tissue coaptation or association with more severe incontinence. Although detrusor overactivity may reduce the efficacy of all devices, medical management can address many of these problems. Ischemic damage of the corpus spongiosum may increase risk of erosion, but in the absence of a traumatic arterial insufficiency to the entire pudendal bed, cavernosal blood flow would not be associated with outcomes of AUS.

3.b. Subcuff urethral atrophy. The narrow-backed AUS model 800 has improved mechanical reliability such that now atrophy is a more common cause of recurrent UI. New-onset detrusor overactivity is rare after AUS but may complicate any surgical treatment. The key is that slow onset of incontinence indicates atrophy, whereas sudden recurrence of incontinence indicates mechanical failure, fluid leak or erosion of the device.

4.d. Artificial urinary sphincter. This patient has a complex history with compromise of both rhabdosphincter and internal sphincter. Bulking agents are a consideration in cases of male urinary incontinence unrelated to radical prostatectomy, but the severity of incontinence makes this unrealistic. Thus, standard bulbar AUS is indicated. After urethral disruption due to pelvic fracture, neither transobturator nor bone-anchored slings are likely to reliably provide effective elevation, elongation, or compression because of distortion of the bony pelvic anatomy and high likelihood of rhabdosphincter damage. Continent diversion should be a last resort.

5.d. Transobturator male sling. The problem of urinary tract access is important to this case. Bulbar AUS will not allow appropriate instrumentation and transurethral resection of recurrent tumors. A male sling will allow passage of a 24-Fr resectoscope and is appropriate for this degree of incontinence. The other variables in this case indicate that this patient is an excellent candidate for a sling device with minimal to moderate urinary incontinence, high leak-point pressure, and no history of radiation. Urinary diversion is premature.

6.a. Catheter drainage for 7 days and delayed replantation. Urethral injury during any implant surgery places the patient at risk for device infection due to the presence of colonizing bacteria in the urethra. The risk of devastating

device infection outweighs any benefit and thus the procedure should be aborted.

7.b. Adjuvant radiation therapy. Radiotherapy is associated with a lower success rate of bone anchored male slings and the transobturator male slings. The other listed conditions have not been associated with poor outcomes. Radiation tends to decrease the efficacy by approximately 50% in all patients undergoing transobturator male sling for stress incontinence.

8.c. Intrinsic sphincter deficiency. The sine qua non of UI post-RP is intrinsic sphincter deficiency. Detrusor dysfunction may be present in as many as 40% of these men, but is the primary cause of UI in less than 5%. Although detrusor overactivity may also be present, it is not a contraindication to moving forward with the treatment for sphincteric incontinence.

9.c. Laser incision with flexible ureteroscope. Dilation with sounds would be potentially risky to the cuff; bulbar cuffs do not allow the safe insertion of standard resectoscopes, making Collins knife incision impossible. The safest approach for an initial stricture would be laser incision through a smaller caliber endoscope such as a ureteroscope. Although exploration of the AUS cuff with uncoupling of the cuff will allow safe endoscopic management of strictures and tumors with resectoscopes, this should be reserved for cases not amenable to simple laser incision with small caliber and scopes. Antegrade incision is feasible but offers less control than the retrograde approach. Open surgical reconstruction should be reserved for refractory cases.

.a. Downsize the cuff to 3.5 cm. This primary failure of AUS likely relates to incorrect sizing of the cuff. Although a tandem cuff or transcorporeal cuff could provide improved coaptation, in a 43-year-old man it is more appropriate to correct the cuff size than use up additional locations on the

bulbar urethra. These will be necessary for future device replacements over time. Increasing the pressure in the PRB may also increase the risk of erosion. Long-term complications of bladder neck cuffs in men with normal vesicourethral junctions are low and the option of a bladder neck cuff placement should be considered before closing the bladder neck in an otherwise adequate bladder.

.d. Choice of PRB. Bladder neck AUS require higher pressures to ensure coaptation. Cuff measurement and PRB location require no modification; connections can be made intra-abdominally or in the subcutaneous space above the fascia; and usually the differences in fluid volume are nominal.

.d. Cystometric capacity of 200 mL or less. The best indicators for patients who may develop overactive bladder after treatment of their outlet for sphincteric incontinence include a capacity of less than 200 mL on urodynamics or diary and the presence of symptomatic overactive bladder before surgical treatment for the incontinence. Patients with prior radiation therapy may develop urgency and frequency at a later time, but this is not a significant risk factor before proceeding with outlet procedures such as male slings or AUS. Leak-point pressure and prior procedures do not indicate a risk

for development of overactive bladder.

.c. Prior transobturator sling surgery. The placement of a transobturator sling before moving forward with an artificial urinary sphincter does not affect the outcomes of the artificial urinary sphincter. Prior erosions with the

need for removal of the device, prolonged catheterization and instrumentation, and prior history of pelvic radiation, as well as hypertension and other comorbidities, do significantly affect the rates of subsequent erosion of these devices.

.c. Visual demonstration of stress incontinence with stress maneuvers.

Before embarking on the surgical management of stress incontinence, absolute requirements in the evaluation include a subjective history of urinary leakage with stress maneuvers, confirmation of leakage on physical exam, urinalysis to rule out infection, and evaluation of the postvoid residual. The inspection of pads soaked with urine is sufficient objective confirmation of leakage. Urodynamics may be helpful in cases where there may be mixed components of incontinence in addition to those cases with prior surgical interventions or other complex cases as indicated. The voiding diary is quite useful when evaluating stress versus urgency component but is still not absolutely required; cystoscopy is also helpful in evaluating the outlet but again is not

absolutely required.

.c. Staphylococcus epidermidis. Gram-positive bacterial infections are most commonly involved in infection of prosthetic devices in the genitourinary system (penile prosthesis and artificial urinary sphincter). Classically, S. epidermidis is most commonly involved on these devices. Although all of the other bacteria and fungal pathogens may also be involved, S. epidermidis is still most common.

.c. AUS with bulbar placement. This patient's history of prior radiation therapy makes the transobturator sling outcome significantly worse. The radiation combined with very high volume of incontinence in a 24-hour period

makes him an excellent candidate for the AUS. Although the device may not make him completely dry, it can significantly reduce the number of pads used per day and improve quality of life.

Chapter review

1.Endoscopic evaluation should precede surgical correction of urinary incontinence following radical prostatectomy or a TURP to evaluate the anatomy and eliminate bladder neck contracture; patients with suspected bladder outlet obstruction, significant bladder overactivity or impaired contractility should be evaluated with urodynamics.

2.An assessment of bladder capacity, compliance, and contractility is required before considering surgical correction of urinary incontinence.

3.Submucosal bulking agents are of limited efficacy in treating incontinence following radical prostatectomy.

4.After artificial sphincter placement, prolonged urinary retention requires suprapubic cystostomy drainage.

5.Determining the appropriate tension of the sling is the most critical portion of the operation.

6.Cuff atrophy requires downsizing, repositioning, tandem cuff placement, or transcorporeal surgery.

7.Incontinence after a TURP is rarely due to external sphincter injury.

8.Significant cognitive impairment puts a patient at risk for inability to safely use an AUS.

9.Radiation therapy and prior urethral surgery are relative contraindications to sling surgery

10.Moderate to severe incontinence is best treated with an AUS rather than a sling.

11.An absolute contraindication for surgical correction of incontinence is a decreased bladder compliance which would jeopardize renal function.

12.After AUS insertion a slow onset of incontinence indicates atrophy while the sudden recurrence of incontinence indicates mechanical failure, fluid leak, or erosion of the device.

13.Bulbar urethral placement of an AUS will not allow appropriate instrumentation and transurethral resection in patients with recurrent bladder tumors.

14.Detrusor overactivity, if present, is not a contraindication to the treatment for sphincteric incontinence.

15.Gram-positive bacterial infections are the most commonly involved in infection of prosthetic devices in the genitourinary system.

PART XIII

Benign and Malignant Bladder

Disorders