MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER

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 -> 12 F 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. 5 cm) 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 33 mo) 87% success rate (1 patient required reoperation and removal for erosion)

SALVAGE OF INFECTED AUS 7 solution irrigation

MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER COMPLICATIONS