MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER COMPLICATIONS

CASE

 78 yo male c ISD following open radical prostatectomy. 3 -5 pads per day    AMS tandem cuff AUS implanted in 2008 Very satisfied with results, able to return to active life of fishing and golfing 5-7 days weekly PMH: Myesthenia Gravis 2010; h/o Prostate Cancer; Depression  PSH: Open Radical Prostatectomy; Tandem Cuff AUS; Right Inguinal Hernia Repair 9/2011  Meds: Cellcept & Zoloft  Social: Retired; Non Smoker; Avid golfer & fisher; Wife Retired OR Nurse

CASE CONTINUED

 October 2011: Presented to ED with a red edematous scrotum & difficulty manipulating scrotal pump. Symptoms developed over 2-3 week period  Denies pain, dysuria, hematuria, fever or chills     Physical Exam AVSS Nl Penis R hemiscrotum mild erythema/induration/pump fixed to scrotal wall/skin dimpled/minimal TTP  WBC 12 UA not sent by ED   Antibiotics US demonstrating simple fluid collection surrounding scrotal pump

CASE CONTINUED

 Labs - WBC 12; UA not sent by ED  Imaging   Scrotal US as outpatient Cystoscopy -> no urethral erosion/no bladder neck contracture  The patient was diagnosed with an infected AUS and taken to operating room on 11/28/11

OR 11/28/2011

 Scrotal Exploration/Explant of Scrotal Pump/Cystoscopy/Placement of Foley Catheter     Indurated/inflammatory rind Clear fluid surrounding pump – cultured Urethral cuffs intact without evidence of infection Deactivation of system in deflated position -> Rubber shad connections -> pump removed -> tubing kinked and tied off  Post Operative Course    PICC Line: Ceftriaxone/Vancomycin Foley D/C in office POD#2 Subsequent cultures all negative

CASE CONTINUED

 12/3/11: Re-presents to the ED with clear liquid drainage from scrotal incision. Catheter removed day prior. No F/C, N/V. No SP TTP   Difficult Foley Pollack/sensor wire -> 12F Foley over wire  Labs: Body fluid Cr collected but not sent by ED  Outpatient urethrogram normal – no extravasation  Catheter removed, patient represented to Memorial c urinary retention  Punch SPT placed 12/8/11

AUS INDICATIONS & CONTRAINDICATIONS

 First developed and implanted in 1974  Over 20,000 devices implanted  Main indications   ISD – post prostatectomy Neurogenic bladder dysfuntion

OUTCOMES OF AUS Components Outcomes



Urinary continence achieved 73% (range 61%-96%)

 Post-prostatectomy continence ≈ 90%

AUS COMPLICATIONS

 Urinary Retention  Urethral Atrophy  Erosion –5 – 15%  Early Infection:   1-3% general 10% pelvic radiation or reoperation (Montague, 1992)  Mechanical Failure   3% device malfunction Less common with newer AMS models

URINARY RETENTION

 Make sure cuff is deflated and pump deactivated  US or Floroscopic guided Suprapubic Tube Placement   Prevent damage to pre-pubic balloon pump Prevent urethral erosion  Retention lasting > 2 weeks may warrant reoperation for cuff upsizing

URETHRAL ATROPHY

 Most common reason of AUS reoperation  Presents with painless increased leakage of urine  Chronic compression of spongy tissue under occlusive cuff  More common in patients with pelvic radiation  Treatment: Re-Operation    Cuff Downsizing Move cuff to more proximal or distal location Tandem Cuff Insertion

EROSION

 5% overall incidence (less common now than in past)  Risk Factors*: HTN/CAD/Pelvic Radiation/AUS Revision  Presentation: UTI/Pain/Fever/Scrotal Swelling/Fistula  Treatment:    Explant of all components Urethral Catheter 2-4 weeks or until no extravasation on urethragram Reimplantation after 3-6 months.

Hussain, 2005 Martins, 1995 Walsh, 2002 * Kim, 2008 * Gohma, 2002

EROSION

 Deactivation  Deactivation for 6 weeks decreased erosion from 18% to 1.3%  Reimplant following erosion    8.7% - 35% recurrent erosion Nightly deactivation recommended Transcoporal cuff may decrease risk further Motley & Barret, 1990 Raj, 2006

MECHANICAL FAILURE

 Early mechanical failure rates 12%  Decreased to 7.6% following introduction of narrow backed cuff and improvement in cuff composition that decreased cuff leak  Actual device failure currently quoted at only 3%  Failures include   kinking of tubing Early experience with large cuff sizes (≥5.5cm) and improper balloon selection

INFECTION

 1-3% rate after implant  RR increased in individuals with pelvic radiation/reoperation  Presentation: Scrotal pain, fixed scrotal pump, erythema  Gross Purulence/Sepsis/Bacteremia/UTI/Ketoacidosis/Immunosupp ression*  Explant of AUS  Is there a role for immediate salvage re implant operation for infected prosthesis?

Hussain, 2005 Martins, 1995 Walsh, 2002 Kim, 2008

SALVAGE OF INFECTED AUS

 8 patients, 9 salvage procedures  5/8 patients Tandem Cuff AUS only  3/8 patients AUS + Penile Prosthesis  Follow-up 5-66 mo (mean 33mo)  87% success rate (1 patient required reoperation and removal for erosion)

7 solution irrigation

SALVAGE OF INFECTED AUS

MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER COMPLICATIONS