人工尿道括约肌治疗真性尿失禁

目的：探讨人工尿道括约肌治疗真性尿失禁的效果和安全性。方法：对1例前列腺电切术后尿失禁患者进行AMS800人工尿道括约肌植入治疗。记录植入术前术后的排尿日记，并观察不良反应。结果：施行人工尿道括约肌植入术后6周开通人工尿道括约肌，尿失禁得到良好地控制，恢复自主排尿，未发生并发症，无其他不良反应，结论：人工尿道括约肌植入术是一种安全有效的治疗真性尿失禁的方法。     

Combined external urethral bulking and artificial urinary sphincter for urethral atrophy and stress urinary incontinence

OBJECTIVE: To describe a technique of externally bulking the urethra with a soft-tissue graft before placing another artificial urinary sphincter (AUS), as when placing another AUS for recurrent male stress urinary incontinence (SUI) other manoeuvres, e.g. placing a tandem cuff or transcorporal cuff, must be used to obtain urinary continence in an atrophic urethra, and each is associated with morbidity. PATIENTS AND METHODS: From January 2003 to July 2004, five patients (mean age 74 years, range 62-84) treated by radical prostatectomy were referred for recurrent SUI after placing an AUS (four, including one with urethral erosion) or a male sling (one, with a resulting atrophic urethra). Each patient was treated with an external urethral bulking agent (Surgisis) ES, Cook Urological, Spencer, Indiana) and had an AUS placed. RESULTS: In each patient the greatest urethral circumference was <4 cm. To place a functional 4 cm cuff, the diameter of the urethra was enhanced by wrapping it with Surgisis ES. Continence was significantly improved in all patients except one 84-year-old man who had the replanted artificial sphincter removed because of erosion 14 months after surgery. CONCLUSION: In cases of severe recurrent SUI from urethral atrophy after placing an AUS, externally bulking the urethra with Surgisis ES before placing another AUS is well tolerated, and gives satisfactory results.     

Outcome of the artificial urinary sphincter in female patients

PURPOSE: We reviewed the outcome in female patients at our unit in whom an artificial urinary sphincter was inserted. MATERIALS AND METHODS: We reviewed notes on 68 patients and mailed a questionnaire to those without recent followup. RESULTS: Median time since insertion was 12 years. Overall 25 patients (37%) had the original artificial urinary sphincter in situ and were dry at a median followup of 7 years. The artificial urinary sphincter was replaced for loss of function in 12 patients, of whom 11 were dry with the replaced device. The device was removed for erosion or infection in 31 patients, of whom 19 underwent successful replacement or were continent after removal. Overall 55 of 68 patients (81%) were continent. Those with neuropathic bladder dysfunction achieved a continence rate of greater than 90%, although half required sphincter removal initially. When the indication for insertion was stress incontinence, 70% of the patients had the original or a replaced artificial urinary sphincter in situ and 82% were continent. All patients with previous pelvic irradiation had the sphincter removed and urinary diversion was done. CONCLUSIONS: The overall continence rate in female patients after insertion of an artificial urinary sphincter is satisfactory. A satisfactory outcome was achieved in terms of stress incontinence and we would recommend an artificial urinary sphincter after an adequate anti-stress incontinence operation fails. Continence in patients with neuropathic bladder dysfunction is excellent and the artificial urinary sphincter should be considered first line treatment in this group, although the risk of revision surgery is high. Pelvic irradiation is a contraindication to the artificial urinary sphincter in female patients.     

25‐year experience in the outcome of artificial urinary sphincter in the treatment of female urinary incontinence

Study Type – Therapy (outcomes research)
Level of Evidence 2c

OBJECTIVE

To report the outcome of artificial urinary sphincter (AUS) in female patients for the treatment of stress urinary incontinence (SUI).

PATIENTS AND METHODS

We retrospectively reviewed all female patients with AUS implanted over the last 25 years in one institution. Patient demographics, renal tract imaging and urodynamics assessment were documented. Outcomes measures included complications, duration and cause of AUS failure. Urinary continence was defined as no pad use after AUS insertion. AUS failure was defined as malfunction, infection or erosion. AUS malfunction included either mechanical (fluid leak) or non‐mechanical (infection or surgical damage to AUS). A Kaplan–Meier analysis was used to determine device failure over time.

RESULTS

In all, 47 consecutive women with a mean (range) age of 51 (17–78) years received an AUS for the treatment of UI. Of these, 35 women had failed anti‐incontinence surgery previously. There were two wound infections after AUS insertion but no mortality. Of the 47 AUS implanted, 39 (83%) AUS remained in situ. Eight (17%) AUS were removed due to AUS erosion or infection. There were 20 AUS revisions, 16 of which were primary AUS revisions. Most of the AUS revisions were related to mechanical malfunctions. Comparison of the proportion of AUS device survival over time using Kaplan–Meier analysis showed >80% of AUS remained functioning after 100 months. At the time of review, 83% of patients had a device in situ and the continence rate with no pads use was 59% with AUS only; this figure increased to 85% when concurrent clean intermittent self‐catheterization was performed.

CONCLUSIONS

AUS is an effective and durable treatment option for female SUI. In properly selected women, high continence rates can be achieved. Most patients maintained satisfactory long‐term continence rates despite revision surgery.     

Treatment of stress urinary incontinence with artificial urinary sphincter

Stress urinary incontinence in women is usually due to either urethral hypermobility or intrinsic urethral weakness. Stress incontinence due to urethral hypermobility is usually cured with a cystourethropexy. That due to intrinsic urethral weakness, however, requires either periurethral injection, sling cystourethropexy or placement of an artificial urinary sphincter to achieve reasonable success rates. The artificial urinary sphincter has been used since 1972. Many modifications have been made to the original device, culminating in the currently available device, the AS-800, made by American Medical Systems. This paper reviews patient selection, surgical technique and complications of artificial urinary sphincter placement in the treatment of women with intrinsic urethral weakness (type III incontinence).     

The Asia-Pacific AMS800 artificial urinary sphincter consensus statement

This Asia-Pacific (AP) AMS 800™ artificial urinary sphincter (AUS) consensus statement aims to provide a set of practical recommendations to assist surgeons with the AMS 800 device surgery. The AP consensus committee consisted of key opinion leaders with extensive experience with AMS 800 surgery across several AP countries. The panel reviewed and discussed relevant findings with emphasis on locoregional and specific clinical challenges relevant to the AP region. Recommendations were made in key areas namely (1) patient selection and informed consent process; (2) preoperative assessment; (3) dealing with co-existing urological disorders; (4) surgical principles and intraoperative troubleshooting; (5) postoperative care; (6) special populations; and (7) cost analysis and comparative review. The AMS 800 device should be offered to males with moderate to severe stress urinary incontinence (SUI). Full informed consent should be undertaken, and emphasis is placed on surgical contraindications and high-risk candidates. The presence of a surgical mentor or referral to experts is recommended in complex AUS candidates. Preoperative cystoscopy with or without multichannel urodynamic study is necessary and patients with pre-existing urological disorders should be treated adequately and clinically stable before surgery. Adherence to strict patient selection and safe surgical principles are critical to ensure excellent clinical outcomes and minimize complications. Given that InhibiZone-coated device is not available in many AP countries, the use of prophylactic antibiotics pre-and post-operatively are recommended. The AMS 800 device should be prepared according to the manufacturer's guidelines and remains a cost-effective treatment for male SUI. The AMS 800 device remains the surgical benchmark for male SUI but is associated with certain mechanical limitations and a unique set of complications.     

Comparison of the long-term outcomes between incontinent men and women treated with artificial urinary sphincter

PURPOSE: We compared the long-term outcome of AUS between men and women who received the device for the management of stress urinary incontinence. MATERIALS AND METHODS: Between August 1983 and January 2004, 126 consecutive patients received the AUS AMS 800 at our center placed by the senior author (ACD). Of these patients 108 (53 men, 55 women) and 168 devices (88 in men, 80 in women) were available for review. Outcome measures include complications, duration and etiology of AUS failure, and satisfactory continence. RESULTS: Mean followup was 8.1 +/- 5.6 years. Of the 108 patients 18 (40%) men and 31 (56%) women had no complications (p = 0.09). Of the 168 devices 76 (45%) eventually failed (44 or 50% in men, 32 or 40% in women, p = 0.19). The incidences of failed device classified as mechanical, nonmechanical or iatrogenic were not significantly different (p = 0.07). Median device durations were 6.9 and 11.2 years in men and women, respectively (p = 0.002). Satisfactory continence was achieved in 82% of patients, in 43 (81%) men and in 46 (84%) women (p = 0.73), including 5 (9%) men and 35 (64%) women who were dry (0 pads, p = 0.01), 28 (53%) men and 4 (7%) women who wear 1 pad (p = 0.01), and 10 (19%) men and 7 (13%) women who use 2 pads per day. CONCLUSIONS: There were no differences in overall satisfactory continence and device failure rates. However, women have a higher dry rate (0 pad use) and longer functioning device duration compared to their male counterparts.     

Laparoscopic artificial urinary sphincter implantation for female genuine stress urinary incontinence: technique and 4‐year experience in 25 patients

Study Type – Therapy (outcomes research)
Level of Evidence 2c

OBJECTIVE

To assess the safety, feasibility and efficacy of laparoscopic implantation of the artificial urinary sphincter (AUS) in women with genuine stress urinary incontinence (SUI).

PATIENTS AND METHODS

From April 2005 to July 2009, 25 women (mean age 66.8 years) with genuine SUI had a laparoscopic implantation of the AUS (AMS 800^TM, American Medical Systems, Minnetonka, MN, USA). Patients had a negative Marshall test and urodynamic studies showed decreased closure pressure. All patients had a history of urogynaecological surgery. Transperitoneal laparoscopic access was created with two midline 10‐mm and two lateral 5‐mm trocars. One of the lateral port incisions was later extended to facilitate urethrovaginal dissection with scissors and dissector, and the insertion and assembly of the AUS. In six cases of concomitant genito‐urinary prolapse, laparoscopic anterior and posterior mesh promontofixation was also performed.

RESULTS

The AUS was successfully implanted in all cases with no conversion to open surgery. There were no intra‐ or perioperative complications, except one vaginal perforation which was repaired during surgery. The mean operative duration was 92 min (71 min without and 123 min with simultaneous promontofixation). Five patients developed urinary retention, which was managed with re‐insertion of the urethral catheter for 2 days in four and with insertion of a suprapubic catheter for 4 weeks in a patient with spina bifida. During the mean follow‐up of 26.1 months, two treatment failures were diagnosed due to vaginal erosion and were managed with removal of the AUS. All the remaining 23 patients reported continence, either complete (in 19) or social (in four). However, this was not a randomized comparative study.

CONCLUSION

Laparoscopic implantation of the AUS in women with genuine SUI is safe, feasible and efficient.     

Artificial urinary sphincter for post‐prostatectomy incontinence: A review

The artificial urinary sphincter remains the gold standard for treatment of post‐prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most commonly implanted artificial urinary sphincter. Having been on the market for almost 40 years, there is an abundance of literature regarding its use, but no recent review has been published. We reviewed the current literature regarding the indications, surgical principles, outcomes and complications of artificial urinary sphincter implantation for stress urinary incontinence after prostatectomy. A PubMed search was carried out for articles on the artificial urinary sphincter from 1995 to present. The review was centered on articles related to the use of the AMS 800 for stress urinary incontinence in males after prostatectomy. Relevant articles were reviewed. The majority of patients will achieve social continence (1 pad per day) after artificial urinary sphincter implantation; however, rates of total continence (no pad usage) are significantly lower. Patient satisfaction outcomes average greater than 80% in most series. Potential complications requiring reoperation include infection (0.5–10.6%) and urethral erosion (2.9–12%). Revision surgeries are most commonly as a result of urethral atrophy, which ranges from 1.6 to 11.4%. The 5‐year Kaplan–Meier freedom from reoperation ranges from 50 to 79%, while the 10‐year Kaplan–Meier freedom from mechanical failure is 64%. The artificial urinary sphincter is a reliable device with good outcomes. As expected with any prosthetic device, complications including mechanical failure, infection, erosion and recurrent incontinence remain significant concerns. Despite known complications, the patient satisfaction rates after artificial urinary sphincter implantation remain high. Appropriate patient counseling and adherence to surgical principles are imperative.     

Outcomes following erosions of the artificial urinary sphincter

PURPOSE: Artificial urinary sphincter urethral cuff erosion occurs in up to 5.0% of cases, presenting a complex management problem. We examine our experience with the eroded AUS, relating to preoperative risk factors, operative management and outcomes. MATERIALS AND METHODS: We reviewed the medical records of 637 patients undergoing bulbar urethral AUS implantation from 1990 to 2003 for demographic and surgical variables. RESULTS: Of the 637 records reviewed, 46 patients underwent 54 explantations of the AUS device for erosions, including 13 who had the primary implant performed at our institution and 33 being referred for management of erosion after implantation elsewhere. Our institution erosion rate was 2.2%. Mean followup after AUS reimplant following erosion was 27.8 months (range 1 to 180). Comorbidities were more prevalent in patients with erosions included hypertension (p = 0.006), coronary artery disease (p = 0.03), prior radiation therapy (p = 0.006) and prior AUS revisions (p = 0.0001). A majority of patients had persistent mild incontinence (0 to 1 pad daily in 29 or 56.8%), moderate (1 to 3 pads daily in 9 or 17.4%) and severe (more than 3 pads daily in 6 or 11.8%) incontinence after secondary AUS implantation. Patients who underwent reimplantation after AUS cuff erosions have a significantly higher rate of second erosions (in 16, 34.8%) within an average of 6.7 months (range 3 to 24), including our own 11.8% institutional rate (in 4). CONCLUSIONS: Our study suggests that patients with comorbidities including hypertension, coronary artery disease, prior radiation therapy and prior AUS revisions are more likely to have erosions of their AUS. Nevertheless, continence can still be salvaged using various strategies which optimize use of the remaining healthy urethral tissue.     

The artificial urinary sphincter in the treatment of incontinence in the female patient

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.     

Objective assessment of urinary incontinence after successful implantation of the ams artificial urethral sphincter

We selected 34 patients who had been fitted with the AMS artificial sphincter (models 742, 791, 792) in 1978–1982, who claimed to have a satisfactory result and compared their subjective feeling of continence to the objectively measured urine loss by a 1-hour padweighing test. Furthermore, we related the measured urine loss to the position and size of the cuff and the balloon pressure; 19 patients claimed to be completely dry, ten patients experienced varying degrees of incontinence with physical activity, and five patients did wear some kind of protection, but all patients were satisfied with the operation. The results of the pad-weighing test showed that 22 patients were completely dry and 12 patients had some measurable urine loss. Patients with an artificial sphincter at the bladder neck had better continence than patients with the sphincter at the bulbous urethra, possibly because of a better transmission of pressure to the cuff from the abdominal cavity. The level of the closure pressure in the balloon in patients with sphincters at the bladder neck was not significantly related to the amount of urine loss. We conclude that patients might be subjectively satisfied with an artificial sphincter operation despite some objectively measured urine loss and that the subjective feeling of continence correlates fairly well with the objective pad-weighing test. When regarding postimplant continence in isolation the bladder neck position of the prosthesis is superior to the bulbous urethra position.     

如何提高人工尿道括约肌植入术的手术效果

人工尿道括约肌（AUS）植入术是治疗各种原因所致括约肌源性尿失禁的金标准。本文阐述了如何提高AUS植入的手术效果、减少并处理近期及远期并发症的临床经验,包括：①严格掌握手术指证。②严格遵循手术原则、标准、条件与时机。③术前充分进行医患沟通。④手术技巧。⑤手术并发症的诊断与处理。⑥其他提高手术效果的新措施。     

The male sling for stress urinary incontinence: urodynamic and subjective assessment

PURPOSE: We prospectively examined whether the fixed urethral resistance of the perineal male sling for the treatment of stress incontinence causes significant bladder outlet obstruction or de novo voiding dysfunction. MATERIALS AND METHODS: A total of 22 patients (average age 67 years old) were evaluated before and after surgery with videourodynamics, the self-administered UCLA Prostate Cancer Index incontinence section and pad score. RESULTS: Mean followup was 25 months (range 6 to 42). All patients complained of a moderate to severe problem before surgery. After surgery 16 (73%) reported a very small problem/no problem, 3 (14%) a moderate problem and 3 (14%) reported a big problem. Average pad use +/- SD decreased from 4.6 +/- 2.5 to 0.74 +/- 1.0 pads (p <0.01). Median UCLA Prostate Cancer Index incontinence score increased from 82 to 313, p <0.001. Mean retrograde leak point pressure (RLPP) increased from 30.4 +/- 15.9 to 59.9 +/- 9.7 cm water. Bladder outlet obstruction did not develop in any patients after surgery. Average maximum flow rate did not change significantly (17.7 +/- 6.5 vs 19.2 +/- 9.7 ml per second, p = 0.6). Nor was there a significant change in detrusor pressure at maximum flow rate (40.3 +/- 9.2 vs 45.8 +/- 14.7 cm water, p = 0.3). While de novo urgency or urge incontinence did not develop in any patients, 2 of 5 patients with a moderate/big leakage problem demonstrated postoperative detrusor overactivity on cystometry. Both individuals requiring more than 3 pads daily had a postoperative RLPP of less than 50 cm water. CONCLUSIONS: Pad use, leak point pressure and urinary incontinence scores are significantly improved after sling surgery. Fixed resistance does not lead to bladder outlet obstruction. Postoperative RLPP less than 50 cm water and urodynamic detrusor overactivity are associated with increased pad use and bother.