Two-stage transperineal management of posterior urethral strictures or bladder neck contractures associated with urinary incontinence after prostate surgery and endoscopic treatment failures

OBJECTIVES: The treatment of posterior urethral strictures or bladder neck contracture associated with severe urinary incontinence after prostate surgery and failure of endoscopic treatments is controversial. We report our experience with a transperineal approach in two steps: end-to-end urethroplasty/anastomosis and subsequent artificial urinary sphincter implantation. METHODS: Between September 2001 and January 2005, we observed six patients (58-68 yr old), with a combination of severe urinary incontinence and posterior urethral stricture with anastomotic bladder neck contracture after prostate surgery. In all cases, repeated endoscopic treatments of the strictures failed. The patients underwent transperineal end-to-end urethroplasty or anastomosis followed by transperineal artificial urinary sphincter placement after 6 mo. RESULTS: After the first surgical step, all patients were completely incontinent with absence of urethral strictures and complete anastomotic healing in all cases. Therefore, all patients underwent artificial urinary sphincter insertion. After a mean follow-up of 38 mo (range: 18-57 mo), five patients are continent with no postvoid residual urine and a perfectly functioning device. One artificial urinary sphincter was removed due to urethral erosion. CONCLUSIONS: In patients with posterior urethral strictures or bladder neck contractures associated with severe urinary incontinence, an artificial urinary sphincter implantation as a second step allows verification of the outcome of a previous end-to-end urethroplasty or anastomosis and utilizes a dedicated operative field to reduce the risks of prosthesis implants.     

Success of the artificial urinary sphincter after failed surgery for incontinence

We implanted the artificial urinary sphincter in 15 incontinent patients for whom multiple urethral and bladder neck operations, including sphincter placement, had been unsuccessful. The 5 male and 10 female patients ranged from 3 to 26 years old (mean age 11 years). The etiology of incontinence was neurogenic bladder in 10 patients, epispadias in 2, exstrophy in 1, ectopic ureters in 1 and traumatic urethral disruption in 1. Of the 15 patients 13 required augmentation enterocystoplasty and clean intermittent catheterization. The initial anti-incontinence procedures were Young-Dees-Leadbetter bladder neck reconstruction in 10 patients, artificial urinary sphincter placement in 4 and bladder neck suspension in 1. Causes of failure of the primary treatment were erosion (artificial urinary sphincter), and incontinence and/or difficult catheterization (Young-Dees-Leadbetter). Followup from the last salvage operation averaged 21 months (range 6 to 37 months). A total of 58 operations was performed. Among the 4 patients in whom the artificial urinary sphincter eroded the bladder neck repeated attempts to place the cuff at the same site were unsuccessful and erosion occurred in all 4 within 1 year. Sphincter placement was more successful among the 11 patients who initially underwent Young-Dees-Leadbetter bladder neck reconstruction or bladder neck suspension; acceptable continence was attained in 8 patients (73%). We conclude that placement of the sphincter cuff around a previously eroded bladder neck probably will result in erosion. Sphincter implantation should be attempted in patients in whom bladder neck reconstruction has failed. Persistence in the treatment of these patients is essential because multiple operations often are necessary to achieve continence.     

Surgical correction of urinary incontinence

Over the last 6 years, 114 patients have undergone surgery for urinary incontinence. The majority (79%) had neurologic dysfunction of the bladder because of spinal malformation (myelodysplasia, sacral agenesis, or trauma) and the remaining were a mixed group including exstrophy/epispadias, urethral valves, pelvic fractures, etc. The patients were grouped in six categories. Those with lower urethral resistance underwent bladder neck reconstruction with Young-Dees-Leadbetter procedure (five patients) or had placement of an artificial urinary sphincter (27 patients). Those with poor bladder compliance underwent primary bladder augmentation (21 patients). Those with combined urethral problems and poor compliance had combined procedures (14 patients). Thirty-seven patients previously diverted for incontinence and undergoing undiversion were considered separately, as were ten patients without any bladder precluding preoperative assessment. Of the entire group, continence was achieved in 83 patients with the initial procedure (73%). Secondary procedures have resulted in continence in 101 patients (89%). Three patients were improved but unsatisfactory, and nine remain wet; one is unknown.     

Treatment of the epispadias-exstrophy complex with the AS792 artificial urinary sphincter

The AS792 artificial urinary sphincter was implanted in 11 incontinent patients with the epispadias-exstrophy complex. To date 10 patients (91 per cent) are totally continent of urine with normal renal function and intact urinary systems. The recent reports concerning success with bladder neck reconstruction in this syndrome are reviewed. Owing to the relatively poor success of this procedure in achieving total urinary continence it is recommended strongly that insertion of the artificial urinary sphincter be the initial anti-incontinence procedure for these patients. The success rate with the artificial sphincter currently is superior to any form of bladder neck reconstruction in patients with the epispadias-exstrophy complex.     

Failed bladder neck reconstruction: options for management

During the last 10 years 17 patients have been seen at this institution for persistent urinary incontinence after Young-Dees-Leadbetter bladder neck reconstruction. Of these patients 16 were born with classical bladder exstrophy and 1 with complete epispadias. Six patients underwent 1, 10 underwent 2 and 1 underwent 3 prior bladder neck procedures. As salvage procedures 8 patients underwent another Young-Dees-Leadbetter procedure, 1 repeat bladder neck reconstruction and augmentation cystoplasty, 3 augmentation alone, 4 bladder augmentation with creation of a continent abdominal stoma and 1 augmentation with implantation of an artificial urinary sphincter. Of the 8 patients who underwent a repeat Young-Dees-Leadbetter procedure 7 are dry for 3 hours or more and 1 is dry for greater than 3 hours on intermittent self-catheterization. All of those who are dry for greater than 3 hours are dry at night and 1 wears pads when engaging in strenuous physical activity. Of the 9 patients who underwent augmentation cystoplasty along with other adjunctive procedures 8 are continent for greater than 3 hours on intermittent catheterization, 6 are dry at night if they perform catheterization at bedtime and 1 remains totally incontinent after removal of the artificial urinary sphincter. Thus, with persistence and creativity a child with a previously failed bladder neck reconstruction or even multiple failed repairs can be made socially continent, providing a satisfactory alternative without resorting to urinary diversion.     

The treatment of sphincter strictures

A group of 25 patients with strictures of the membranous urethra following transurethral resection of the prostate (TURP) were investigated and treated initially by careful urethral dilatation. This controlled the stricture in 14 patients, 6 of whom continued with occasional dilatation or self-catheterisation to maintain control; 8 required an artificial urinary sphincter (AUS) and 2 required a "clam" ileocystoplasty for detrusor instability. Eleven had persistent or recurrent strictures requiring urethroplasty. Nine underwent bulbo-prostatic anastomotic urethroplasty, 4 with simultaneous bladder neck reconstruction and 5 with subsequent implantation of an AUS; 2 had a preputial patch urethroplasty with subsequent implantation of an AUS. Four of the 9 patients with a urethroplasty and an AUS are satisfactory, 1 developed a recurrent stricture and 2 developed erosions. Two of those with a bulbo-prostatic anastomosis and bladder neck reconstruction are satisfactory and 2 are incontinent. These results were compared with those of 18 other patients who underwent bladder neck reconstruction and 12 who had a urethroplasty in conjunction with an AUS for reasons other than a post-TURP sphincter stricture. The success rate of bladder neck reconstruction was 55% and the success rate of urethroplasty in conjunction with an AUS was 83%, but the main complication of AUS implantation, erosion, was a more serious problem than failure of bladder neck reconstruction. However, the much higher success rate makes AUS implantation a more satisfactory procedure. Surgery should be avoided if at all possible and reliance placed on urethral dilatation.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Urodynamic and ultrasound characteristics of incontinence after radical hysterectomy

AIMS: To test whether symptoms of urinary incontinence after radical hysterectomy could be objectified with urodynamics and ultrasound. METHODS: This case-control study comprised 100 women who underwent radical hysterectomy for cervical cancer without post-operative radiotherapy. Fifty women reporting urinary incontinence were matched with 50 women reporting continence. All women were assessed with ultrasound of the bladder neck movements and urodynamics. RESULTS: No differences were found in ultrasound or urodynamic findings regarding mobility of the bladder neck, maximal detrusor pressure, post-voiding residual urine, flow of urine, or bladder capacity. A significant reduction in urethral pressure at rest and at contraction among the incontinent women was, however, demonstrated. Among urge-incontinent women, urethral pressure at rest was significantly lower than among continent and stress-incontinent women, respectively. Stress-incontinent women had significantly lower urethral pressure at contraction than did urge-incontinent and continent women. CONCLUSIONS: No differences in urodynamic or ultrasound findings were observed between the two groups, except for an overall difference in the intraurethral pressure. A decrease in the urethral pressure could contribute to the characterization of incontinence after radical hysterectomy, indicating that the urethral sphincter mechanism plays a role in the pathophysiology. In this study design, the mobility of the bladder neck did not play any role.     

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic Alternatives

Purpose

We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children.

Materials and Methods

From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3).

Results

In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries.

Conclusions

As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapubic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.     

Urinary continence after repair of membranous urethral stricture in prostatectomized patients.

Prostatectomy by open or transurethral techniques usually destroys the function of the internal sphincter (bladder neck), which is the first line of defense against incontinence. Urinary continence then depends upon the intrinsic smooth muscle sphincter of the membranous urethra and the striated external sphincter. Unfortunately, a significant incidence of membranous urethral stricture occurs after a prostatic operation. Most such strictures can be managed with periodic dilatation but some are difficult and dangerous to dilate. Complications such as recurrent acute retention, bacteremia, false passages, stone formation, fistulas and so forth are indications for surgical cure of the stricture. However, can urethroplasty of the membranous urethra be carried out in these patients without inevitable incontinence? At our center 33 prostatectomized patients have had a 2-stage urethroplasty for refractory membranous urethral strictures. Nine patients had troublesome stress incontinence after the first-stage operation but only 4 of these had continuing incontinence after the second-stage operation. These patients had been noted to have transient postoperative stress incontinence after the prostatectomy. Although there is a risk of incontinence after urethroplasty of the membranous urethra in prostatectomized patients, the risk is sufficiently low that the operation should not be denied patients with refractory strictures in whom the only alternative eventually will be some form of urinary diversion.     

Management of urinary incontinence after bulboprostatic anastomotic urethroplasty for posterior urethral obstruction secondary to pelvic fracture

OBJECTIVE: To present our experience of the management of urinary incontinence after bulboprostatic anastomotic urethroplasty for post-traumatic posterior urethral obstruction secondary to pelvic fracture. MATERIAL AND METHODS: Between 1979 and 1998, we managed 13 patients with postoperative incontinence after bulboprostatic anastomotic urethroplasty. Of these patients, nine had undergone a transpubic approach and four a perineal approach. The causes of urinary incontinence in the 13 patients were as follows. Ten patients had derangement of the proximal sphincteric mechanism (the distal sphincteric mechanism is usually destroyed as a result of trauma and/or during urethroplasty). These 10 patients were managed by placement of an anterior bladder tube, after the failure of pharmacological manipulations. Two patients who had been managed by transpubic urethroplasty experienced complications due to vesicourethral fistulae. They were managed by excision of the tract and repair of the bladder and the urethral defects. One patient, who was managed additionally by visual urethrotomy (for postoperative obstruction after perineal bulboprostatic anastomosis), experienced complications due to a false tract between the bladder and urethra. He was managed by bulboprostatic anastomosis and excision of the false tract. RESULTS: After 1-6 years follow-up, the outcome of the 10 patients who underwent placement of a bladder tube was good in four (40%), fair in three (30%) and poor in two (20%). The two patients who presented with vesicourethral fistulae regained continence after excision of the fistulae. The patient who had a false tract between the bladder and urethra regained continence after revision of the bulboprostatic anastomosis and excision of the fistulous tract. CONCLUSIONS: The proximal sphincteric mechanism should be fully evaluated before performing bulboprostatic anastomosis. Placement of a bladder tube is a good option for managing urinary incontinence. Vesicourethral fistulae are an unrecognized cause of urinary incontinence following transpubic urethroplasty. Visual urethrotomy should only be used in short, passable strictures.     

Pelvic fracture‐related injuries of the bladder neck and prostate: their nature,cause and management

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report our experience of bladder neck injuries, which are a well recognized but rare consequence of pelvic fracture‐related trauma to the lower urinary tract, as we have been unable to find any reference in the English literature to their specific nature, cause and management in adults.

PATIENTS AND METHODS

In the last 10 years we have treated 15 men with bladder neck injuries after pelvic fracture. Two were treated at our centre by delayed primary repair. Thirteen were initially treated elsewhere and presented to us 3 months to 5 years after their injury with intractable incontinence and various other symptoms most notably recurrent urinary infection and gross haematuria. Twelve of the injuries were at or close to the anterior midline and associated with lateral compression fractures or ‘open‐book’ injuries. Five of them were confined to the bladder neck and prostatic urethra; the other seven extended into the subprostatic urethra. Four of these were associated with a coincidental typical rupture of the posterior urethra. All had an associated cavity involving the anterior disruption of the pelvic ring. Two of the injuries, following particularly severe trauma, were a simultaneous complete transection of the bladder neck and of the bulbo‐membranous urethra with a sequestered prostate between. We have seen this in children before but not in adults. Another injury, also after particularly severe trauma, was an avulsion of the anterior aspect of the prostate. We have not seen this described before. Fourteen patients underwent lower urinary tract reconstruction and one underwent a Mitrofanoff procedure. All of the 14 had a layered reconstruction of the prostate and bladder neck and in 13, this was supplemented with an omental wrap.

RESULTS

In all patients with an anterior midline rupture, the primary injury appeared to be to the prostate and prostatic urethra with secondary involvement of the bladder neck and the subprostatic urethra. The Mitrofanoff procedure was successful. Of the 14 patients with a layered reconstruction one, without an omental wrap, broke down but was successfully repaired on a subsequent occasion. The four patients who also had a ruptured urethra had a simultaneous bulbo‐prostatic anastomotic urethroplasty, two of which required further attention. Eight of the 14 reconstructed patients underwent implantation of an artificial urinary sphincter (AUS) for sphincter weakness incontinence, in seven of whom this was successful. Two of these had previously undergone implantation of an AUS with an unsatisfactory outcome and were made continent by bladder neck reconstruction. The other six patients had acceptable urinary incontinence by reconstruction of the bladder neck and urethra alone.

CONCLUSIONS

The primary injury is to the prostate and prostatic urethra. The bladder neck and subprostatic urethra are involved secondarily by extension. These injuries have a particular cause and a particular location with a predictable outcome. They need to be identified and treated promptly as they do not heal spontaneously and otherwise cause considerable morbidity. We also describe two particular types of bladder neck injury that we have not seen described before in adults.     

Reconstruction of Membranous Urethral Strictures

Purpose of Review

Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures.

Recent Findings

Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.

     

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.     

Urinary incontinence after non-nerve-sparing radical prostatectomy with neoadjuvant androgen deprivation

OBJECTIVES: The impact of non-nerve-sparing retropubic radical prostatectomy (RRP) for prostate cancer combined with neoadjuvant androgen deprivation on urinary control is not well documented. We examined the incidence and severity of urinary incontinence after such therapy and determined the etiologic factors causing this complication. METHODS: We examined the postoperative continence status of 104 consecutive patients admitted to the National Cancer Center Hospital who underwent RRP with wide resection of the pelvic nerves after neoadjuvant androgen deprivation. Incontinence was scored according to the number of pads used daily by the patient for urinary leakage. The severity of incontinence was analyzed according to patient age, weight of resected specimen, status of cancer stage, duration of neoadjuvant androgen blockade therapy, preoperative length of membranous urethra, and duration of urethral catheterization after surgery. We also measured the configuration and diameter of the reconstructed bladder neck by retrograde cystourethrography. RESULTS: In 104 patients examined, the percentage of patients who became dry postoperatively was 22% at 1 month, 47% at 3 months, 69% at 6 months, and 78% at 1 year. Of 81 patients who became dry postoperatively at any interval, 22 (27%) became continent within 1 month of RRP, 49 (61 %) were continent within 3 months, 71 (88%) became continent by 6 months, and another 10 (12%) became continent between 6 and 12 months postoperatively. Of 48 patients who were followed up for more than 1 year and for whom continence status at 1 month after surgery was available, all patients who used 1 to 2 pads per day (13 of 13) at 1 month after surgery regained continence by 1 year after surgery. However, only 62% of patients (16 of 26) who required more than 3 pads per day at 1 month after surgery became dry by 1 year after surgery. Only age (older than 70 years) and large prostate size (weight of surgical specimen more than 40 g) temporarily influenced the recovery of urinary continence after surgery. Dilation of the bladder neck evaluated by retrograde cystourethrography was prominent in severely incontinent patients in the immediate postoperative period. CONCLUSIONS: Our experience in patients who undergo non-nerve-sparing RRP after neoadjuvant androgen deprivation closely matches published surveys of patient-reported complications. Postoperative incontinence is not a major contraindication for non-nerve-sparing RRP after neoadjuvant endocrine therapy. Dilation of the bladder neck affected the recovery from incontinence, highlighting the importance of adequate reconstruction of the bladder neck.     

The model AS 800 artificial urinary sphincter: Mayo Clinic experience

The model AS 800 artificial urinary sphincter was implanted in 100 male and 9 female patients between 7 and 89 years old. Postoperative followup was 1 to 32 months. The indication for implantation was total urinary incontinence in 86 patients (78.9 per cent), stress incontinence in 22 (21.2 per cent) and urgency incontinence in 1 (0.9 per cent). Of the patients 97 (89 per cent) underwent implantation for the first time, 7 (6.4 per cent) had a previous artificial urinary sphincter model replaced by the AS 800 device and 5 (4.6 per cent) underwent reimplantation of a previous model. The cuff was placed around the bladder neck in all 9 female patients, whereas in the male patients the cuff was implanted around the bladder neck in 20 and around the bulbous urethra in 80. Thirty-one patients (28.4 per cent), 29 of whom were continent at night, were practicing nocturnal deactivation of the device. Complete post-activation continence was achieved in 91 patients (83.5 per cent), some leakage occurred in 10 (9.2 per cent) and 8 (7.3 per cent) remained incontinent. A total of 23 patients required 1 or more revisions, the most common indications for the first revision being loss of cuff compression (9), tubing kink (3), cuff erosion (3) and infection (2). At the time of this report 89 patients (81.7 per cent) were continent, 9 (8.3 per cent) still had some leakage, 3 (2.8 per cent) were incontinent, 5 (4.6 per cent) were awaiting reimplantation and 3 (2.8 per cent) had died of unrelated causes.     

Use of the AS792 artificial sphincter following urinary undiversion

Reconstruction of the urinary tract after diversion has been successful in patients with normal innervation of the lower tracts. However, the possibility of urinary incontinence after such major surgical procedures has dissuaded many surgeons from attempting urinary undiversion in patients in whom the continence status cannot be determined accurately before the operation or who were known to be incontinent before the original diversion. For this reason, the presence of neuropathic bladder dysfunction has been considered a relative contraindication to urinary undiversion unless it can be established preoperatively that the patient will obtain urinary continence. Eight patients are reported who had successful outcome with the use of the AS792 artificial urinary sphincter to control incontinence after urinary undiversion. Because of this successful experience it is now believed that patients with neuropathic bladder dysfunction or anatomically abnormal lower tracts are no longer precluded from urinary undiversion. A variety of methods has been used to reconstruct the urinary tract, including total reconstruction of the bladder and urethra with the sigmoid colon in 1 case. In the latter case the artificial sphincter was placed around the bowel segment to provide continence. The use of the artificial sphincter around a bowel segment offers many possibilities for reconstructive procedures involving bowel in the future.     

Effect of radical prostatectomy on sensory threshold and pressure transmission

PURPOSE: The mechanisms involved in post-radical prostatectomy incontinence remain unclear despite previous anatomical and functional studies. In addition, the factors responsible for the restoration of continence are not well studied. To improve our understanding of the alterations in continence mechanisms, we prospectively investigated the temporal changes in urodynamic parameters after radical prostatectomy. MATERIALS AND METHODS: Cystometry, urethral pressure profilometry and posterior urethral sensory threshold measurements were performed in patients undergoing radical prostatectomy. Preoperative pressure transmission was determined by the maximal urethral pressure divided by the maximal abdominal pressure during cough maneuvers at a bladder volume of 200 ml. Postoperative sensory threshold, pressure transmission (% of pressure transmission), maximal urethral closure pressure and functional sphincter length were measured 6 weeks and 6 months after prostatectomy. These parameters were compared between continent and incontinent patients. RESULTS: Preoperative and postoperative urodynamic studies were completed in 34 patients. The continence rate after 6 weeks was 18% (6 patients) and improved to 82% (28) after 6 months. Preoperatively sensory threshold was 16 +/- 11 mA. After 6 weeks and 6 months, respectively, sensory threshold was significantly higher in incontinent (84 +/- 11 mA., 70 +/- 8 mA.) compared to continent (65 +/- 8 mA., 41 +/- 12 mA.) patients. Preoperative proximal urethral sensory threshold was not correlated with degree of postoperative incontinence determined by pad tests. Pressure transmission was not different in continent and incontinent patients postoperatively. After 6 weeks and 6 months, respectively, pressure transmission was 77% and 91% in continent, and 37% and 58% in incontinent patients (p = 0.04, p = 0.03). Maximal urethral closure pressure was significantly higher in continent patients (35 +/- 6 cm. H2O) compared to incontinent patients (11 +/- 9 cm. H2O). Sphincter length decreased from 50 mm. preoperatively to 24 mm. after 6 weeks and 25 mm. after 6 months. There was no difference in sphincter length between continent and incontinent patients. CONCLUSIONS: Posterior urethral sensitivity and pressure transmission are impaired immediately after prostatectomy. An improvement in these parameters after 6 months is associated with the restoration of continence. These observations suggest that urinary continence after radical prostatectomy depends on the integrity of posterior urethral sensation and the efficiency of pressure transmission.     

Management of type III stress urinary incontinence using artificial urinary sphincter.

Type III stress urinary incontinence due to severe intrinsic urethral weakness without significant urethrovesical descensus may be treated by periurethral injection, sling cystourethropexy, bladder neck reconstruction, or artificial urinary sphincter implantation. The rationale for procedure selection depends on a number of patient factors and the surgeon's experience. We herein report on 25 women who were identified as having such incontinence by evaluation which included videourodynamic study and lateral voiding cystography and who were managed by the implantation of an artificial urinary sphincter. The etiology of the severe intrinsic urethral weakness in most patients was multiple prior failed cystourethropexies. Postoperatively, 1 patient died of a cerebral vascular accident. The remaining 24 women had significantly improved continence and were completely satisfied at latest follow-up. No revisions have been required for patients receiving an artificial sphincter after 1983. No sphincter erosions or infections have occurred. Our experience and review of the literature shows that the artificial sphincter provides an excellent first option for women with type III urinary stress incontinence due to intrinsic urethral weakness of various etiologies.