Editing Functional: Surgery for Male SUI (section)

=== Persistent Incontinence after Surgery (AUS or sling) ===
* '''Causes'''
*# '''Inadvertent deactivation'''
*# '''Insufficient urethral compression (oversizing of cuff)'''
*# '''Cuff erosion'''
*# '''Bladder storage failure'''
*# '''Mechanical failure with fluid loss'''
*# '''Plugged delay-fill resistor'''
*# '''Kinked tubing'''
* '''Timing'''
** '''After AUS insertion,'''
*** '''A slow onset of incontinence suggests atrophy'''
*** '''The sudden recurrence of incontinence indicates'''
**** '''Mechanical failure'''
**** '''Fluid leak'''
**** '''Erosion of the device'''
* '''Inadvertent deactivation'''
** '''Active cycling of the device excludes inadvertent deactivation'''.
*** '''If the pump is deactivated with inadequate fluid to cycle, passive filling can be achieved by squeezing the pump on its lateral edges or by pushing on the pump with a cotton-tipped applicator opposite the deactivation button'''.
* '''Mechanical failure with fluid loss'''
** '''Plain radiography (for contrast-filled systems) or ultrasonography (for saline-filled systems) of the pressure-reservoir balloon during cycling can help differentiate fluid loss from cuff atrophy.'''
*** '''If the pressure-reservoir balloon size changes with cycling and refills passively, mechanical failure is less likely and thus suggests cuff atrophy'''
* '''Cuff erosion'''
** '''Cystoscopy, in addition to excluding erosion, can be used to visualize the cuff during cycling and give insight into the likelihood of atrophy.'''
* '''Bladder storage failure'''
** '''Urodynamics should be performed when bladder storage failure is suspected'''
*** '''The best indicators for patients who may develop overactive bladder after treatment of their outlet for sphincteric incontinence include (2):'''
***# '''Bladder capacity < 200 mL on urodynamics or diary'''
***# '''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.
* '''Revision surgery for non-mechanical causes may require (3):'''
*# '''Tandem cuff'''
*# '''Modified cuff placement using 3.5-cm cuff'''
*# '''Transcorporeal placement'''
** '''When the cause of persistent UI is incomplete urethral occlusion, the addition of a second tandem cuff around the bulbar urethra can yield satisfactory continence.'''
*** Connection to the existing device requires division of the existing cuff tubing and use of a metal Y connector. An additional 3 mL of fluid must be added to the system.
** '''However, in a relatively young patient, the cuff should be downsized rather than placing a second cuff to avoid using additional locations on the bulbar urethra, which will be necessary for future device replacements over time.'''