Urinary tract deterioration associated with the artificial urinary sphincter

In most recent series of artificial sphincter implantations there has been a reduction in mechanical and surgical complications, with continence rates approaching 90 per cent. Despite initially excellent results in 47 children, with increasing durations of followup we noted a transient hydronephrosis related to incomplete bladder emptying in 5 and a persistent physiological alteration of detrusor dynamics consisting of a rigid, noncompliant bladder in 7. Preoperatively, all patients had had indepth radiological studies and most had a urodynamic evaluation, and were considered to be excellent candidates. The etiology of these alterations is not understood at this time. Bladder and even upper tract deterioration can occur without the appearance of urinary leakage. Therefore, children with an artificial sphincter must be monitored indefinitely with semiannual assessment of the upper tracts and periodic urodynamic evaluation.     

Upper urinary tract deterioration after implantation of artificial urinary sphincter

The preoperative urodynamic evaluations of twenty patients with myelomeningocele who had had artificial sphincter implantation because of urinary incontinence were reviewed. Four patients developed hydronephrosis and severe impairment of renal function between two and six years after implantation of the artificial sphincter. The condition was partly reversible after removal of the artificial sphincter. The urodynamic evaluation prior to implantation revealed in the four mentioned patients compared to the 16 patients with normal upper urinary tract, a tendency to lower bladder compliance, lower bladder capacity and more severe detrusor hyperreflexia, but it was not possible to make a clear discrimination between the two groups. Attention is drawn to this unfortunate combination of effects after artificial sphincter implantation. Periodic control of the upper urinary tract by urography is recommended.     

Reconstruction of the lower urinary tract: observations on bowel dynamics and the artificial urinary sphincter

In 14 patients the lower urinary tract was reconstructed using bowel and the artificial urinary sphincter. Of these patients 11 underwent augmentation cystoplasty. The ileocecal segment was used in 4, cecum in 4 and ileum in 3. Total reconstruction of the lower urinary tract was done using the sigmoid colon in 2 patients and an ileocecocolonic segment in 1. Significant bowel contractions were seen in all segments of the large bowel, including the ileocecal segment, which resulted in urinary incontinence in 3 patients with the artificial urinary sphincter and reflux in 3. The ileal cup-patch technique consistently produced low bladder pressures with excellent compliance and an adequate volume. Because of the unpredictable bowel contractions observed in the ileocecal, sigmoid and cecal segments we recommend that augmentation cystoplasty be performed using the cup-patch technique. This procedure will ensure the virtual absence of bowel contractions, and is associated with excellent compliance and capacity.     

Further experience with the artificial urinary sphincter

Since December 1977, 78 patients with severe urinary incontinence have been treated by insertion of an artificial sphincter at our medical center. In 53 patients the device was inserted and activated at the same time. Of these 53 patients 21 (40 per cent) are perfectly dry, 8 (15 per cent) are improved but are occasionally wet and 24 (45 per cent) have failed. In 25 patients activation of the sphincter was delayed. Of this group 14 patients (56 per cent) are perfectly dry, 2 (8 per cent) are occasionally wet and 9 (36 per cent) have failed. The delayed activation technique has reduced the failure rate from 45 to 36 per cent and we recommend its use in high risk patients.     

Surgical results with artificial urinary sphincter

From June, 1974, until January, 1977, eleven AMS 721 genitourinary sphincters were installed in 9 men and 2 females. Long term success was achieved in 2 men. Failures were encountered in 9 patients (82 per cent) with urethral erosions (3 patients), infection (1 patient), and mechanical failure (5 patients) accounting for the complications necessitating prosthetic removal. From January, 1979, until May, 1981,15 males had the revised AMS model AS 742 (b) or (c) sphincter installed. Long term continence was achieved in 9 patients (60 per cent). Urethral erosion in 4 patients (27 per cent) and infection of the prosthesis in 2 men (13 per cent) accounted for failures. An improved surgical technique involving the installation of the device in a defunctionalized state with secondary activation is anticipated to improve future results.     

"Flowsecure" artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence

IntroductionTo spread de concept of a new artificial urinary sphincter with conditional occlusion for stress incontinence. The new prototype was conceived and designed in The Institute of Urology and Nephrology of London by Professor Craggs M. and Professor Mundy A.R.MethodsThe FlowSecure sphincter consists of an adjustable pressure-regulating balloon, a stress relief reservoir, a control pump and valve assembly unit with self-sealing port and a urethral cuff. The pressure regulating balloon determinates de operating pressure of the device; the pressure is adjustable in the range 0-80 cm H2O and can be altered by injection or removal of normal saline through the self sealing port. The stress relief balloon transmits transient intrabdominal pressure to the cuff during periods of stress. An adjustable circular urethral cuff minimises creasing and possible stress fractures.ResultsThe device is implanted as a one-piece assembly which is pre-filled with sterile saline. The surgical technique is simple and associated with little handling, reducing risk of infection and potential assembly errors. The adjustable pressure regulating balloon in association with the stress relief reservoir enables the cuff occluding pressure to be set at a low range, therefore reducing the risk for atrophy and erosion.DiscussionThe new FlowSecure urinary artificial sphincter with conditional occlusion is designed to provide good continence rates adjusting regulating pressures when needed and conceived to reduce the risk of potential complications associated with excessive occluding pressures and mechanical failures.     

"FlowSecure" artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence

introductionWe have implanted the FlowSecure artificial sphincter for the first time in October 2006. The prototype was originally conceived and designed by Professor Craggs M. D. and Professor Mundy A.R. Preliminary clinical results were reported in nine patients early this year. Our objective is to spread technique for surgical implantation.MethodsCombined perineal and abdominal incisions are required for exposure of bulbar urethra, creation of a cavity in the para-vesical space and dissection of a pocket under de scrotal wall. A trocar with a stylet is routed from the abdominal incision to the perineal incision to pass the deflated cuff to the perineal site. The cuff is placed around the urethra and secured with Prolene sutures. After refilling the cuff, fluid is removed from the system until the stress relief balloon becomes just indented (atmospheric pressure 0). The pump is placed in the scrotum and the balloons in the paravesical space.ResultsWe have implanted our first FlowSecure artificial sphincter in a patient with severe stress incontinence following a T.U.R.P. The surgical technique is simple and associated with little handling. He was discharged from hospital 4 days after the procedure and it was decided that pressurisation was unnecessary.DiscussionSurgical implantation of the new FlowSecure artificial urinary sphincter is an easy procedure in males with stress urinary incontinence. Knigth et al. reported 30 to 40 minutes operating time, 4 days mean hospital stay and unnecessary pressurisation procedure in 3 out of their 9 patients. It seems that their results are reproducible.     

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).     

Management of urinary incontinence in women with the artificial urinary sphincter

This study concerns 39 women who underwent implantation of the artificial urinary sphincter for severe, persistent urinary incontinence following surgical correction of the anatomical deformity. The cause of incontinence was poor or absent function of the urethral sphincteric mechanism. The success rate in this series with the artificial urinary sphincter was 92 per cent. The condition of the tissues in the cuff area is crucial for success of the procedure. Some technical considerations of the procedure are discussed.     

Urinary undiversion and implantation of the artificial urinary sphincter in a 73-year-old man

We report a case of successful urinary undiversion and implantation of an artificial urinary sphincter in a 73-year-old man, who had undergone ileal loop urinary diversion elsewhere for treatment of urinary incontinence secondary to transurethral prostatectomy. The rationale for our decision to perform undiversion is presented. Evaluation of patient history and physical examination are necessary, as well as delineation of the anatomy and function of the upper and lower tracts by laboratory, radiological and urodynamic examinations. Each undiversion case is unique. Treatment must be individualized and should be initiated only after meticulous weighing of the advantages and disadvantages of the different therapeutic alternatives. A complete explanation to the patient is important. Highly satisfying results can be expected in appropriately selected cases.     

Urinary tract infection associated with urinary calculi. 1. The significance of urinary tract infection in urinary calculi

We investigated 158 cases of urinary stones (infection stones 56, metabolic stones 102) with special reference to pyuria, bacteriuria, stone culture and urease activities of isolated bacteria. Abacterial pyuria was noted in 9 out of 49 (18%) infection stones and in 53 of 77 (69%) metabolic stones. Bacteriuria was noted in 79% of the infection stones and 26% of the metabolic stones. Sixty-seven percent of the infection stones were infected with mainly urea splitting bacteria such as Proteus mirabilis and Staphylococcus. Twenty-three percent of metabolic stones were also infected. Though E. coli, a non-urea splitting bacteria, was isolated most frequently from metabolic stones, urease positive Staphylococcus and Pseudomonas were also isolated. Bacteria within stones could be predicted on the basis of urine culture results of only 20 of 41 infection stones and 8 of 24 metabolic stones. These facts are useful for selection of some antibiotics in the treatment of urinary tract infections associated with urinary calculi. Urinary infections of urea splitting bacteria in infection stones are thought to be initial factors of stone formation and those of non-urea splitting bacteria are to be superimposed. However, urea splitting bacteria in metabolic stones may convert them into infection stones in future.     

Experience with the penile prosthesis and artificial urinary sphincter

The therapy of two common urologic problems, erectile dysfunction and urinary stress incontinence, has been revolutionized over the last 20 years by the incorporation of principles of hydraulic mechanics into the field of silicone prosthesis implantation. The inflatable penile prosthesis is surgically implanted into men with impotence due to organic or psychogenic etiology. The artificial urinary sphincter has found widespread use in males and females in both the adult and pediatric populations with stress incontinence from a variety of causes. Associated with these popular devices are various complications relating to the anatomic site as well as the host's immunologic response. The use of these implants, as well as the technologic innovations resulting from various adverse effects, are reviewed herein.     

Experience with the artificial urinary sphincter at Michigan.

Between August 1973 and May 1975, 9 patients with various causes of urinary incontinence were treated with the implantable artificial sphincter. Of these 9 patients 6 remained continent on long-term followup. Complications, observed in 5 patients, were corrected successfully in 2 but were treated unsuccessfully in 3 and resulted in partial or complete removal of the prosthesis. The need for screening the patient preoperatively, meticulous operative techniques and continuous postoperative surveillance is emphasized. An orderly method of evaluating the problem is presented.     

Management of neurogenic urinary incontinence with AMS artificial urinary sphincter

The AMS artificial urinary sphincter was implanted in 33 patients with neurogenic urinary incontinence during a 10-year period. All sphincter types were employed, from the earliest AS 721 model to the latest AS 800. The mechanically unstable AS 721 and 761 types have all been removed and, when possible, replaced by later models. In 27 of the 33 patients the device is still in situ, and in 6 (18%) it was removed, mainly because of urethral erosion. Increasingly favourable sphincter survival rats have been obtained. The overall survival rate for model AS 742 was 55% (7 years) for first implant, while the 4-year survival rate for AS 791/792 was 90%. Successful control of voiding function, defined as complete continence or slight but not socially inconvenient incontinence, was obtained in 25 patients (76% of the series).     

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。     

Urinary undiversion with implantation of an artificial urethral sphincter

Urinary undiversion was performed in a 21-year-old man with a contracted flaccid bladder. The steps of the procedure were: bladder dilatation; antireflux implantation of an ileal conduit into the bladder; external sphincterotomy, and implantation of an artificial urethral sphincter. The patient is continent and has a good bladder capacity and emptying. In many patients with urinary ileal conduit diversion, upper urinary tract and stomal problems develop after some years. In these patients urinary undiversion must be considered but, so far, evaluation showing a high risk of postoperative incontinence has been regarded as a contraindication to urinary undiversion. However, the introduction of artificial urethral sphincters has made it possible to perform undiversion procedures in many of these patients in whom the bladder capacity and bladder emptying is acceptable, if a nonobstructed outlet is secured. We describe the findings and procedures in a patient undergoing urinary undiversion with implantation of an artificial sphincter 8 years after urinary diversion due to neurological disorders caused by a myelomeningocele.