Artificial Urinary Sphincter
Cuff placement
- Place patient in low lithotomy, ensure far enough down on bed for full perineal access, shave, prep, drape, give vancomycin + gentamicin or alternative, place capped catheter
- Optional - cystoscopy prior to ensure no bladder neck contracture
- Make midline perineal incision down to bulbospongiosus, place lone star retractor with hooks for retraction (use larger circle inferior)
- Divide bulbospongiosus, then free up urethra using sharp dissection, ensure enough length proximal and distal, dissect until able to safely get right-angle clamp around urethra
- Bring vessel loop around urethra to maintain access
- Measure urethra to assess size, do not overly tighten
- Bring right-angle behind urethra from same side as PRB placement, grasp cuff and pull through
- Use rubbershod clamps to put cuff together without introducing air
Pressure regulating balloon (PRB) placement
- Choose suprapubic location within lateral portion of rectus, make transverse incision and cut down to anterior rectus fascia
- Tag fascia with superior and inferior PDS stitches, then make transverse fascial incision between them
- Develop submuscular space through this window, then place balloon and inflate with 20mL
Pump placement
- Place spongestick through PRB incision aiming inferiorly and laterally down to scrotum, once inside ipsilateral scrotum open and spread to create a space
- Bring pump down into scrotum, ensure it does not retract
Connecting and finishing
- Develop space through PRB incision down to perineal incision, should be able to palpate small amount of tissue between fingers in both incisions
- Use blunt needle passer to pass cuff tubing up to PRB incision site
- Once tubing passed, start closing perineal incision - spongiosum, subcutaneous, then skin
- Use connecting device to connect tubing together, trim redundant tubing prior if needed
- Close PRB incision with subcutaneous and skin stitches
- Apply dressing, leave foley x24hr
Surgery tips
- Single vs tandem: single cuff via perineal approach is preferred, tandem cuff has increased explant rate (17% vs 4%)
- Urethral injury: can consider repair of small injury with absorbable suture and cuff placement at alternate location, otherwise abandon placement
Postoperative recommendations
- Avoid sitting on hard objects for long periods of time
- Avoid cycling for 6 weeks, activate in office and ensure patient able to cycle
- Consider deactivating at night to provide urethral rest
- Deactivate AUS prior to catheter placement, minimize time with catheter
Complications
- Hematoma: most common complication
- Infection: 3-5%, usually within 2 months placement, assess for erosion via cystoscopy, wait 3+ months before reimplanting
- Urinary retention: may be due to urethral edema, ensure cuff deactivated, perform CIC with small catheter, consider SPT placement