10 / 70
M
ale
urinary
incontinence
: A
rtificial
sphincter
R
ev
A
ssoc
M
ed
B
ras
2017; 63(8):664-680
667
high scrotal incision. This technique was followed for 24
months with no difference in continence rates.
30
(B)
The
surgeon usually selects the lowest balloon pressure need-
ed to maintain closure of the bulbar urethra or bladder
neck. The most commonly used balloon pressure is 61-70
cm / H
2
O (45-51 mmHg) (94% of cases worldwide). A
pressure of 71-80 cm of H
2
O may be preferred in patients
with a cuff implanted in the bladder neck.
31
(D)
The prosthesis may be filled with isotonic sterile so-
dium chloride solution or contrast, at the surgeon’s discre-
tion. The solution must be isotonic to minimize the trans-
fer of fluid through the semipermeable silicone membrane.
Some contrast materials are hypertonic and viscous, rep-
resenting a risk of poor transmission of fluid in the device
and transfer of fluid through the reservoir membrane.
System pressure changes may occur over time if the balloon
is filled with radiopaque solution at an incorrect concentra-
tion.
32
(C)
A history of adverse reactions to the radiopaque
solution prevents its use as a filling medium for the pros-
thesis. If contrast solution is used, the manufacturer’s
recommendations must be observed.
6
(D)
The filling volume of the PRB with the empty cuff
should be 22-27 cm, depending on the size and number
of cuffs.
31
(D)
The manufacturer’s recommendation is for the PRB
to be filled with 22.5-23 cc of solution while the cuff is
empty, subsequently allowing it to fill with at least 2 cc
of solution remaining within the PRB in order to maintain
the desired pressure range. In selected cases, intraoperative
cuff pressurization may be considered to help determine
the appropriate volume of total system solution.
6
(D)
The length of hospital stay will depend on the time of
removal of the urethral catheter. A 12-Fr urethral catheter
can be placed at the end of the procedure and left in posi-
tion overnight. Others advocate not using a catheter, al-
lowing the patient to attempt emptying after recovery from
anesthesia. If the patient fails to do so, a new catheter is
replaced and a further attempt at emptying it is repeated
in 24-48 hours. In the event of persistent urinary retention
(catheter > 48 h), a suprapubic cystostomy is preferred in
order to reduce the risk of early erosion.
32
(C)
33,34
(B)
The
“AUS Consensus Group” (2015) recommends the use of a
≤ 14-Fr catheter and suggests removing it after a brief pe-
riod (usually overnight) if the surgery was uneventful, as
removal on the same day may increase the risk of urinary
retention due to pain or inflammation.
31
(D)
Several before-and-after studies show an average time
of six weeks for activation of the system.
35-38
(C)
A before-
-and-after study applied a longer period of primary deacti-
vation (12 weeks) in irradiated patients. There is no evidence
to support a primary deactivation period greater than six
weeks. The “AUS Consensus Group” (2015) recommends
the activation of the system between 4 and 6 weeks for
patients undergoing the first AUS implant.
31
(D)
Global evidence summary
The choice of cuff size should be made through the precise
measurement of the circumference of the tissue around
the urethra or the bladder neck. When in doubt, choose
the largest size, avoiding placement of a cuff smaller than
the measurement of the urethral circumference.
(B)
The surgeon should select the lowest balloon pressure
needed to maintain closure of the bulbar urethra or blad-
der neck. The most commonly used balloon pressure in
the bulbar urethra is 61-70 cm/H
2
O and 71-80 cm of H
2
O
may be preferred in patients with a cuff implanted in the
bladder neck.
(D)
The prosthesis may be filled with isotonic sterile
sodium chloride solution or contrast, at the surgeon’s
discretion.
(C)
The filling volume of the PRB with the empty cuff
should be 22-27 cm, depending on the size and number
of cuffs.
(D)
The catheter left in the postoperative period can be
≤ 14-Fr and should be removed after a brief period (usu-
ally overnight).
(D)
In the case of persistent urinary retention, the place-
ment of suprapubic cystostomy is preferable in order to
reduce the risk of early erosion.
(B)
The AUS can be activated between 4 and 6 weeks in
patients submitted to their first implant.
(D)
2. P
reoperative
period
The objective of our evaluation is to suggest preoperative
care for patients with indication of artificial urinary
sphincter, based on primary studies.
Clinical question
How should the preoperative evaluation be performed in
patients who will undergo artificial urinary sphincter im-
plantation? This question was answered in our evaluation
using the PICOmethod, where P stands for patients with
moderate to severe urinary incontinence; I to intervention
with artificial urinary sphincter; C to comparison with tak-
ing or not taking certain preoperative conduct; andO to the
beneficial or harmful outcome in the postoperative period.
Based on the structured question, we identified the keywords
used as the basis for searching evidence in the databases and
after the eligibility criteria (inclusion and exclusion), which
were selected to answer the clinical query (Annex II).