Functional: Surgery for Male SUI: Difference between revisions

* '''Non-surgical (6):'''

*#'''Duloxetine (a serotonin norepinephrine reuptake inhibitor)'''

* '''Surgical (5):'''

*# '''Transurethral bulking agent'''

*# '''Adjustable balloon devices (ProACT)'''  

*# '''Bulbar urethral sling'''

*# '''Artificial Urinary Sphincter (AUS)'''

*# '''Bladder neck closure with diversion'''

==== <span style="color:#ff0000">'''Pelvic floor muscle exercises (PFME)/Pelvic floor muscle training (PFMT)'''</span> ====

* Factors to consider include the severity of UI and associated bother; patient characteristics, including BMI, prior surgical procedures, adjuvant radiation therapy, bladder function, and cystoscopic findings; manual dexterity and cognitive function; efficacy of the various implants; long-term risk for complications and reoperation; and patient preference

== Technique of implantation ==

* '''AUS'''

** '''Cuff is most commonly placed around bulbar urethra via a perineal incision. The aim is to place the cuff as proximal on the bulbar urethra as possible, proximal to the convergence of the corporeal bodies'''

** '''Summary of Steps:'''

*** After incision of the skin, Colles fascia, and bulbospongiosus muscle, the Buck fascia is incised as it reflects off the bulbar urethra onto the diverging corporeal bodies.

*** The circumference of the urethra is measured around the corpus spongiosum to guide selection of cuff size, '''most commonly 4 or 4.5 cm.'''

*** The tubing from the AUS cuff is passed through the overlying bulbospongiosus muscle into the deep perineal space beneath the Colles fascia.

*** '''The placement of the pressure-regulating balloon may be achieved through a scrotal, perineal, or abdominal incision, depending on prior surgical incisions, body habitus, and surgeon preference.'''

**** '''Contraindications to the scrotal/perineal approach:'''

****# '''Mesh hernia repairs'''

***** '''In such cases, the abdominal approach reduces the risk for bladder or intestinal injury'''

*** '''The pump assembly is placed into the anterior scrotum''' '''from the inguinal, scrotal, or perineal incision.'''

*** '''Adequate coaptation of the urethra is verified via urethroscopy.''' '''The closed cuff should cause slight blanching of the urethral tissue''', indicating adequate urethral coaptation, filling, and connection of the device.

** '''Bladder neck AUS'''

*** '''Remains an optional, although more invasive, method of cuff placement in men with sphincteric UI in whom the prostate is without external surgical or traumatic disruption.'''

== AUS Complications ==

=== Intraoperative urethral injury ===

* '''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. The defect should be repaired and a catheter inserted for 7 days'''

=== Urinary retention ===

 

* '''The rate of infection with initial AUS surgery is 1-3%'''

* '''Skin pathogens (staphylococcus epidermidis (most common) and staphylococcus aureus) are the most commonly cultured organisms'''

* '''Diagnosis and Evaluation'''

** '''Initial presentation of an early postoperative AUS infection is usually scrotal pain, although can be erythema, edema, and frank purulence'''

* '''Management'''

** '''Almost always require explantation'''

*** Implant infections are not amenable to antibiotic therapy

*** Traditional management includes device removal followed by a waiting period of several months with delayed reimplantation.

*** '''Immediate salvage of infected, noneroded AUS can be accomplished with complete device removal, antiseptic irrigation, and immediate reimplantation'''

**** '''Contraindications to salvage include sepsis, ketoacidosis, necrotizing infection, immunosuppression, and the finding of gross purulent material at the time of explantation'''

 

 

* Occurs in up to 5% of AUS implantations

** '''Introduction of narrow back modification of AUS has reduced the risk of erosion'''

* '''Risk factors:'''

** '''Campbell’s: radiation therapy, prior erosions with the need for removal of the device, prolonged catheterization and instrumentation, hypertension and other comorbidities'''

*** '''No increased risk of erosion with prior transobturator sling'''

** SASP 2016: '''radiation therapy, prior erosions''' or infection in a previous AUS, a '''prior urethroplasty''', '''multiple endoscopic treatments for bladder neck contracture or urethral stricture, or prior urethral stent placement'''. There is also a much lower but still significant increased risk of erosion with a '''prolonged postoperative catheterization interval''' (> 48 hours), '''or use of either a 3.5 cm or transcorporal cuff compared to a standard 4 cm cuff'''.

*** '''No increased risk of erosion with increasing age, proximal or distal bulbar urethral placement of the AUS, or prior radical prostatectomy'''

* '''Management'''

** '''Immediate removal of all the components of the AUS is imperative because they are assumed to be infected.'''

** '''The urethral injury is managed with urethral catheter drainage''' and/or suprapubic cystostomy

 

 

* '''Most common cause of gradual return of incontinence and revision of the AUS'''

* '''Management'''

** '''Options:'''

*** '''Cuff downsizing'''

*** '''Movement of the cuff to a more proximal or distal location where the urethra may be thicker'''

*** '''Placement of a second cuff in tandem'''

 

=== Mechanical failure ===

* '''7-10-year device life for the AUS'''

* '''Management'''

** '''In the absence of infection or erosion, replacement of an isolated malfunctioning component may be feasible if the revision occurs within 3 years of implantation.'''

*** However, a slow leak from the PRB may be difficult to diagnose intraoperatively, and, if in doubt, total device replacement is prudent.

** '''Devices older than 3 years old should be replaced in entirety.'''

=== Persistent incontinence ===