Artificial Urinary Sphincter Reimplantation
Short summary
81-year-old male that suffers from mixed incontinence with a prominent component of stress incontinence, following a transurethral procedure. Initially attempts were made to gain continence by a Lenzi's procedure, electro stimulation and various anticholinergis. All in all without satisfactory response. He underwent implantation of an artificial sphincter, the AMS AS 800 (AUS) that provided continence and the patient was content with the end result. The AUS was functioning fine until the patient underwent a road accident trauma, then a sphinteric prosthesis malfunction occurred. Infrascopic prosthesis test found absence of the balloon reservoir. Therefore, a prosthesis replacement was scheduled.
Patient's questions
In the light of the bellow mentioned, the following questions are asked:
1) What are the centers of excellence in Italy or, in second instance, abroad for this advised operation to be performed?
2) Do you agree with the advised operation? Are there any other treatment options?
Medical Background
Sex: M, Age: 81 years old
Diagnosis: Artificial urinary sphincter reimplantation.
Case history:
In April 1994 hospitalization at the Urology ward of the Magenta Hospital due to severe urinary incontinence from mixed cause with clear stress-related elements.
The urethral dysfunction occurred about 1 year before following the endoscopic cervico-urethral disobstruction operation carried out in another facility.
It has to be reported that in July 1993 a surgical operation was carried out in order to correct the sphinteric dysfunction according to Lenzi’s method that provides for a sinking of the urethra in the corpus cavernosum. Despite from this therapeutic attempt, the patient kept showing a severe urinary incontinence mostly orthostatic. Treatment consisted of a conservative therapy with anticholinergic drugs and of a perineal electrostimulation without achieving any appreciable result.
Therefore, hospitalization was carried out before the one performed in April 1994 at the Urology Ward of the Magenta Hospital during which the patient underwent the case evaluations in order to confirm the possibility of an artificial sphincter implantation. Such evaluations gave evidence of a high excretory duct within normal limits; the bladder showed normal capacity in the absence of refluxes and mainly in the absence of residual intravesical obstructions with a complete reservoir emptying.
On 04. 1994 the patient, therefore, underwent surgical operation of Scott’s AMS 800 artificial urinary sphincter implantation at the urethral bulb (4.5 cm cuff; 61-70 cm water balloon; osmolarity of 343 milliosmoles/liter). The postsurgical course was normal except for a small hematoma in the scrotal pump that, however, did not bring about a sphincter inflammation.
At the follow-up examination carried out on 10.1994 the patient confirmed a perfect continence with good flow and a prosthesis activity which appeared to be normal. The patient had to compress the pump only once and apparently a good filling of the cuff was reached after miction. In the same occasion an uroflussometry was carried out. It showed a maximum urinary flow 42mL/sec with absent ecograph residue.
The two renal parenchymas appeared to be normal without any pyelo-ureteral dilatation.
Until the end of 2006 a good working of the implanted system.
In January 2007 the patient underwent specialist examination with Dr S. of the Spinal Unit Niguarda Hospital in Milan since, following a road accident trauma, a sphinteric prosthesis malfunction occurred; X-rays examined gave proofs of “outward balloon disappearance”. An evaluation of the infrascopic system was, therefore, scheduled, in the meantime the patient was suggested to handle the incontinence with an external receptacle.
On 02. 2007 infrascopic prosthesis test was carried out with finding of absence of the balloon reservoir. Therefore, the prosthesis replacement was scheduled. From February 2007 till today patient is still on the waiting list at Niguarda Hospital without any precise indications about further waiting times.
Medical opinion
As the patient was examined by a spinal cord specialist, I assume the patient sustained some kind of a back injury. Is it so??
However, since the MVA the patient is suffering again from urine incontinence. Radiological and endoscopic evaluation demonstrated disruption and therefore malfunction of the AUS.
To note, it requires extreme forces to disrupt the prosthesis.
As from then, the patient is wet and controls his incontinence with some kind of a condom catheter and absorbables.
Considering all the above mentioned information I would suggest:
Urodynamic evaluation - The patient had initially some component of mixed incontinence. As the patient sustained some kind of a back injury, the component of detrusor instability may exacerbate. The degree of instability needs to be evaluated and controlled before any procedure is carried out.
More than that. The patient is currently incontinent more than 2 years. The CMG phase needs to evaluate his current bladder capacity and compliance. A diminished bladder capacity would compromise the result of any anti incontinence procedure.
Assuming the urodynamic evaluation would demonstrate no other pathology other than stress incontinence I would opt reimplanting a new AUS. As the previous AUS was implanted 15 years ago I would NOT use any parts of the previous one. The explantation of the previous cuff should not be technically difficult and as in most cases the device creates a pseudo capsule, I would place there the new cuff.
Departments I can recommend in Italy are, the Department of Surgery and Division of Urology, San Paolo Hospital, Savona, and Clinica Urologica II, University of Florence, Florence, Italy.
Other centers of excellence are Dr. Tim Boone, Department of Urology, The Methodist Hospital, Houston, Texas, USA and Dr. Daniel Elliott, Mayo Clinic, Department of Urology, 200 First St. S.W., Rochester, MN 55905, USA.
Obviously, if you are interested we can perform the procedure in my Dept. of Urology, Bnai Zion MC, Haifa Israel.
The "Advance" male sling by AMS – an evolving technology that is gaining popularity on the last 3 years, is for mild to moderate incontinence and therefore is not my first choice. Still, after quantifying the degree of leakage during urodynamics, this is a technique to consider.
Places with more experience with the device are:
Dr. Peter Rehder, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria and Dr. C. Gozzi, Department of Urology,
Klinikum Grosshadern, Ludwig-Maximilians-Universität München, 81377 München, Germany.
