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KW - Artificial urinary sphincter
A new type of artificial sphincter is being developed utilizing a spring-loaded mechanism for applying circumferential pressure in the urethra, which is easy to implant and simple to use. This artificial urinary sphincter is the Tape Mechanical Occlusive Device (TMOD) (GT Urological LLC, Minneapolis, MN), a one-piece device that is manually controlled by the patient through its ON/OFF buttons .
Knight et al. presented 9 male patients (mean age 66 years) with urodynamically proven stress incontinence due to radical prostatectomy treated with implantation of FlowSecure sphincter. The patients were followed for a minimum period of 12 months. All 9 patients recovered well from surgery. Two devices had to be removed for technical reasons. The mean leakage for the remaining 7 patients prior to implantation was 771 ± 658mL corresponding to a continence index of 54%. Twelve months later the leakage had statistically significantly reduced to 52 ± 36mL (P ]. In another study by Rodriguez et al. 100 patients with stress urinary incontinence of various etiologies underwent bulbar urethra (96%) or bladder neck (4%) implantation of a FlowSecure device. All patients had tried conservative treatments and also 59 patients had undergone unsuccessful surgical procedures (suburethral slings, bulking agents, Proact, and AUS-800). Nine patients had undergone previous pelvic radiotherapy. At implantation the sphincters' pressure was left at atmospheric level in all cases. Patients attended for initial pressurization 2–4 weeks postoperatively and were recalled at two-week periods for evaluation and repeat pressurization, if it was required. Overall, 3 pressurizations procedures were required to achieve socially satisfactory continence in 89 patients. The implanting procedure lasted in average 38–47 minutes. Mean inpatient stay was 4.3 days. 53 patients had postoperative self-limited scrotal hematoma. Implants had to be removed in 28 patients (28%) due to early infection (8%), late infection secondary to pressurization procedures (5%), perforation of the pump at pressurization (9%), and mechanical failure (6%). No erosions were noted .
KW - artificial urinary sphincter
The FlowSecure sphincter is a one-piece device consisting of two reservoirs placed in the paravesical space, a cuff that surrounds the urethra and a control pump with a self-sealant port that is placed in patient's scrotum (). The first reservoir regulates resting urethral pressure and the other relieves stress pressure during intra-abdominal increase. During bladder filling the cuff connected with the pressure regulating reservoir compresses and keeps the bulbar urethra closed at low pressure. When intra-abdominal pressure rises, the stress relief balloon provides additional pressure to the cuff to maintain continence. The fluid pressure of the prosthesis may be regulated by injecting or removing saline through the self-sealing port in the control pump located in patient's scrotum . When the patient wishes to void he only has to press the control pump until a good urine flow is achieved. In this way the cuff is emptied by moving the fluid from it to the pressure-regulating reservoir. Redirection of fluid flow and filling of the cuff is recovered when compression on the pump stops .
There are a significant number of men in which ED and SUI coexist, especially in the postprostatectomy population that contributes to a significant decline in quality of life. In a study by Wille et al., data on 327 men who had undergone radical prostatectomy was presented. The authors found a statistically significant higher rate of incontinence among men who had poor erectile function both before and after surgery . Some men who present with urinary incontinence tend to be so much bothered by this problem that they overlook their concomitant ED, and, therefore, men considering sphincter implantation should undergo careful questioning about their sexual function, and vice versa, before any intervention.
KW - artificial urinary sphincter
The Artificial Urinary Sphincter (AUS) 800 (American Medical Systems, Minnetonka, MN, USA), despite the new surgical treatment options (slings, injection of bulking agents, stem-cell therapy), remains the gold standard for persistent moderate-to-severe stress urinary incontinence due to Intrinsic Sphincter Deficiency (ISD) [, , ]. In effort to keep the good success rates and improve some disadvantages of AUS 800 (high cost, complications, and relative difficult insertion), four new devices have been developed in recent years . We attempt to present technical characteristics and insertion procedures for these devices and to report safety and efficacy data, where they are available.
In conclusion, FlowSecure artificial urinary sphincter is easy to implant, with low risk of mechanical failure, and adjustable to the patient's continence needs. Its main purpose is to achieve total patient continence during periods of raised abdominal pressure while subjecting urethra to the lowest possible pressure during resting. Urethral ischemia potentially leading to atrophy and erosion is thus prevented . Use of one-piece prosthesis also decreases the risk of infection due to intraoperative handling and minimizes the chance of mechanical failure derived from errors during assembly . All these may predict a promising future. However, more time and studies will be needed to define the role of this sphincter in the management of stress incontinence resistant to other treatments.
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* Artificial Urinary Sphincter
Introduction Frequently encountered morbidities after prostatectomy include stress urinary incontinence and erectile dysfunction. Patients with severe disease may undergo placement of both a penile prosthesis (PP) and an artificial urethral sphincter (AUS). Aim We hypothesized that concomitant PP may promote AUS cuff erosion by impaired corporal blood flow and/or direct pressure on the cuff. The aim of this study was to compare the rate of AUS cuff erosion in patients with and without a PP. Methods We reviewed 366 AUS operations at our tertiary center between 2007 and 2015 with a mean follow-up of 41 months (range 6–104). Included in the analysis were first-time AUS cuff erosions. Patients with recurrent erosions, AUS revisions, and iatrogenic erosions were excluded. In a separate analysis, we analyzed AUS explantations for all causes. Cohorts were compared by demographic information, preoperative characteristics, and rates of erosion and explantation. Main Outcome Measures Erosion confirmed by cystourethroscopy and explantation of the AUS for all causes. Results Among 366 AUS surgeries at a mean follow-up of 41 months, there were 248 (67.8%) AUS alone cases compared to 118 (32.2%) AUS and PP cases (AUS/PP). Sixty-two patients met exclusion criteria for first-time cuff erosion. Among 304 evaluable AUS patients, we found a significantly higher rate of erosion in the AUS/PP group (11/95, 11.6%) compared to the AUS alone group (9/209, 4.3%, P =.037). When examining explantations for all causes in the entire cohort (n = 366), we observed a significantly higher rate of device removal, (20/118, 17%) in the AUS/PP group compared to the AUS group (23/248, 9.2%, P =.044). Conclusion AUS/PP patients appear to have a higher risk of AUS cuff erosion and explantation compared to men with AUS alone.
The artificial urinary sphincter in the ..
Technical developments have led to a reliable artificial urinary sphincter prosthesis for female patients with otherwise intractable urinary incontinence. Candidates include patients with post-operative stressincontinence or congenital or acquired neuropathic dysfunction. Proper patient selection requires extensive urologic examinations in order to guarantee a high success rate. The most serious complications are due to cuff erosion or infection. With proper operative techniques continence rate is now about 90% in female patients. A new application of the sphincter prosthesis is seen in reconstructive procedures of the lower urinary tract, often with the use of intestinal segments. Careful follow up is warranted in patients with an artificial sphincter since the upper urinary tracts must be monitored and bladder function controlled.
HCPCS Code C1815 for Prosthesis, urinary sphincter (implantable).
Erectile dysfunction (ED) and stress urinary incontinence (SUI) from urethral sphincteric deficiency is not an uncommon problem. The commonest etiology is intervention for localized prostate cancer and/or radical cystoprostatectomy for muscle invasive bladder cancer. Despite advances in surgical technology with robotic assisted laparoscopic prostatectomy and nerve sparing techniques, the rates of ED and SUI remain relatively unchanged. They both impact greatly on quality of life domains and have been associated with poor performance outcomes. Both the artificial urinary sphincter and penile prosthesis are gold standard treatments with proven efficacy, satisfaction and durability for end-stage SUI and ED respectively. Simultaneous prosthesis implantation for concurrent conditions has been well described, mostly in small retrospective series. The uptake of combination surgery has been slow due in part to technical demands of the surgery and to an extent, a heightened anxiety over potential complications. This paper aims to discuss the technical aspect of concurrent surgery for both disease entity and the current published outcomes of the various surgical techniques with this approach.
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