Insertion of Artificial Urethral Sphincter (AUS)

Definition

Artificial = synthetic

Urethra = tube from the bladder through which you urinate Sphincter = a ring-shaped valve that prevents flow

The indication for this operation is to correct urinary incontinence (the involuntary loss of urine). The procedure is usually performed in males. Although there are different types of urinary incontinence , an AUS is placed as a last resort for stress incontinence (loss of urine with coughing, sneezing, lifting, etc.) or total incontinence (the constant dripping or leakage of urine).

In the male, urinary continence is basically maintained by the bladder neck, an internal sphincter and an external sphincter. The internal sphincter is closest to the bladder (near the neck of the bladder). You cannot control its activity, and it is therefore referred to as an “involuntary” sphincter. The external sphincter is just below the region of the prostate. It is called a “voluntary” sphincter because you can control its closure should you need to do so. The prostate only minimally contributes to urinary continence. The bladder neck can close tightly enough to prevent dripping. Some prostate procedures prevent the bladder neck from closing.

When all of the sphincters have been injured or malfunction, there may be chronic loss or dripping of urine. Common causes include:

• a prostate procedure done through a small telescope (endoscopic) in which the sphincter is inadvertently injured (i.e. TURP)
• an open procedure on the prostate such as radical prostatectomy for cancer or suprapubic prostatectomy for benign enlargement
• effects of past radiation treatments; most commonly for prostate cancer
• history of severe trauma to the urethra such as in a motor vehicle accident
• history of urethral surgery to remove strictures (scars in the urethra) if the bladder neck had previously been unable to close

The basic concept of an AUS is that it performs the job of a sphincter. It resembles a tiny inner-tube that is wrapped around a short segment of your urethra. When a pump is squeezed, it deflates the inner-tube and allows the urethra to open. Urine will then drain from the bladder. The inner-tube then automatically regains its fluid so that it once again squeezes the urethra shut. Depending on the volume of fluid in the bladder, it may take more than one “squeeze cycle” to fully empty.

In most instances, we may have tried medications, offered more simple options, or attempted less invasive maneuvers prior to offering placement of an AUS. Although this is a fine option, and one that is usually effective, it does require that the patient have a certain degree of manual dexterity and full understanding of the potential problems.

*It is important that you realize the need for you to properly work the sphincter once implanted.

Preparation

*It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you are known to have problems with constipation, you should consider taking an enema the evening before the surgery.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

The duration of the operation varies for every patient, reflecting the differences in each patient’s anatomy, and whether there is scarring in the area of surgery. In general, an AUS procedure takes 2-3 hours.

The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preference as well as that of your surgeon. General anesthesia(complete sleep) or a spinal are acceptable. Your position on the table will be supine (flat on your back), or in lithotomy position (supine with your legs gently elevated in holsters called stirrups).

The first part of the operation involves placing a catheter down the urethra (tube through which you urinate) and into the bladder. This allows us to feel the urethra during surgery. In many instances, the entire procedure will be done through an incision in the suprapubic area(lower abdomen). It may be up and down or from left to right. In these cases, the sphincter will be placed around the neck of the bladder (the portion in which the bladder becomes the urethra). In other circumstances an incision would also be made in the perineum (the area between the scrotum and the anus). This approach is used when the surgeon wishes to place the sphincter on a more distal (further from the bladder) portion of the urethra. This approach might also be preferable when there is significant scarring in the pelvis from prior surgeries or trauma. Some surgeons will use only an incision in the perineum for some cases. After the sphincter is placed around the selected portion of the urethra, the other two parts of the mechanism are placed in their respective positions. The reservoir (cylinder that holds the fluid) is placed alongside the bladder. The pump (portion that you will squeeze to pen the sphincter)will be placed in the scrotum (male patients) or in the labia majora (female patients). All three portions are connected by tubing in such a way that there is no air in the system.

Throughout the procedure, the operative field is irrigated with antibiotic solutions. After the device is implanted, the areas are irrigated one again and the incisions are sewn closed. Sterile bandages are then applied.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Sometimes, this operation can be done on an ambulatory basis and so you will be sent home. As mentioned, you may have a urethral catheter draining your urine, and this catheter may give you a sensation that you need to urinate. Some surgeons prefer not to leave a catheter. The sphincter will not be inflated yet and so you will still be incontinent of urine. Depending on the choice of incisions, you may have sterile dressings on your suprapubic area and/or the perineum. You may feel some discomfort, but it is uncommon to have severe pain.

The following morning, the catheter will be removed (if present), and you will be discharged home with instructions for follow-up in our office. If you were sent home with a catheter, you will either return to our office to have it removed or be instructed on how to remove it yourself. Other than your regular medications, you may be given a prescription for an antibiotic and a pain medication. Other medications are rarely necessary but depend on your particular needs.

At home, it is important that you really take it easy for a few days. We strongly encourage you to take one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a sitting reclined or lying down position. Periodic walking is encouraged. If you had an incision in the perineum, you may notice some swelling and bruising in this region. It is helpful to apply ice compresses to the perineum as instructed. You should not remove any dressings unless instructed to do so. You may shower the day after your surgery, but no baths or swimming until instructed to do so. Some surgeons will instruct you to take warm baths a couple of times per day a few days after your surgery.

Expectations of Outcome

Most patients are quite satisfied with the results of the procedure. It is important to realize that the sphincter is in a “deactivated” mode after the surgery. You will not be using it until we “activate” it (inflate the inner-tube) many weeks later. The reason that we wait is to allow adequate time for tissue healing around all of the parts.

You cannot engage in any form of sexual activity until we tell you that you may. This is typically for several weeks.

Once activated, it may take practice before you are adept at locating the pump in the scrotum or labia and properly inflating and deflating the sphincter.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Infection: Infection is the most worrisome complication of any surgery in which an artificial device has been implanted. Despite all precautionary measures, infection can occur. It can be a urinary tract infection (presenting with urinary frequency, urgency, and burning) that most often responds to a course of antibiotics. Infection in the surgical site may be more serious. It could present with redness, swelling, fevers, chills, whitish to yellowish drainage, or persistent pain. Those at greatest risk are patients with diabetes. If antibiotics and local wound care are unsuccessful, part of, or the entire device will need to be removed. In this instance, it is best to wait several weeks before re-implanting a new one. If an infection enters the blood stream, you may feel very ill. This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. Often, the patient needs a short hospitalization for intravenous antibiotics, fluids, and observation. This is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.
• *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Mechanical Failure: Like any other mechanical device, it is possible for the parts to malfunction. It can be early, or more commonly years later from chronic use. In this instance, the prosthesis can often be removed and replaced in the same operation. In other instances, there may be too much scarring around the urethra.
• Urethral Injury: The urethra is the tube through which you urinate. While dissecting around the urethra (in order to place the sphincter) it is possible to make a hole in it. This injury may end the procedure. If so, a catheter would remain in the urethra for one to two weeks to allow healing. The AUS placement would have to be rescheduled.
• Blood Loss/Transfusion: Blood loss from this procedure is usually minimal to moderate. If blood loss is more significant, transfusion may be necessary.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery or trauma. The cause is not always apparent. While this usually resolves with time, persistent pain may warrant treatment by a specialist or rarely removal of the prosthesis.
• Erosion: If the sphincter is forcibly pressing up against the urethral tissue over an extended period, it can slowly erode through the urethra even in the absence of infection. Part of or the entire device may need to be removed.
• We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.