RAMB - AGOSTO 2017

ale

urinary

incontinence

: A

rtificial

sphincter

ssoc

ras

2017; 63(8):664-680

673

late onset urinary incontinence) after artificial urinary

sphincter implantation, considering primary studies.

Clinical question

What conduct should be adopted for therapeutic failure

of urinary incontinence after implantation of the artificial

urinary sphincter? This question was answered in this

evaluation using the PICOmethod, where the P stands for

patients with moderate to severe urinary incontinence

presenting therapeutic failure after implantation of the

AUS model AMS800®, I to intervention with evaluation

and conduct during failure and O to outcomes with reso-

lution of persistent or relapsed incontinence. Based on the

structured question, we identified the keywords used as

the basis for searching for evidence in the databases and

after the eligibility criteria (inclusion and exclusion), which

were selected to answer the clinical query (Annex VI).

Results

In all, 1,764 studies were retrieved. Of these, 30 were se-

lected by title and 26 by summary, with reading of the

full text in the second case. After analysis of the full texts,

24 studies were included in this evaluation.

9,15,17,23,24,53,77-90

The main reason for exclusion was that they did not re-

spond to the PICO.

A careful clinical history and a focused physical ex-

amination guide the subsequent investigations necessary

to determine the cause of incontinence after implantation

of the AUS.

Inadequate AUS operation is the most common cause

of immediate UI post-activation. Patients should be taught

to completely deflate the cuff and need to understand

that emptying the bladder takes time, knowing that re-

peated recycling may be necessary.

The control pump, if poorly placed in the scrotum,

may also be accidentally compressed and cause involuntary

deflation of the cuff and UI. When this happens the patient

will complain of incontinence in certain body positions.

The sitting position, with support directly on the urethral

cuff, can also trigger its opening (direct compression). This

can be solved by avoiding hard or pointed seats.

Overactive bladder (OAB) symptoms occur in up to

25% of post-prostatectomy patients and may be associated

with urinary tract infection. Symptoms of

de novo

OAB,

such as urgency, frequency, nocturia and urgency inconti-

nence may develop in up to 23% of patients who did not

present these symptoms preoperatively. Those with pre-

operative OAB will have persistent symptoms in up to 71%

of cases.

(C)

A history of urgency urinary incontinence

prior to AUS implantation may suggest the diagnosis of

detrusor overactivity. Whenever the pathophysiology re-

mains doubtful, urodynamic evaluation is recommended

in order to guide treatment.

(D)

Treatment should be

similar to that of any overactive bladder.

(D)

If the patient does not present continence after AUS

activation (4-6 weeks post-implantation) in the postop-

erative period, the most common problem is a very large

cuff or a very small reservoir. If the urethral cuff is too large,

the coaptation of the urethra becomes insufficient, result-

ing in persistent incontinence.

(C)

The diagnosis of a cuff

with a loose fit can be done by reviewing the surgical notes,

urethral pressure profilometry (performed with the cuff

in the inflated and deflated modes), urethroscopic evalu-

ation and retrograde perfusion sphincterometry with flex-

ible cystoscope.

(C)

In some cases, the reservoir balloon

may not offer sufficient pressure for adequate urethral

coaptation, which can be viewed cystoscopically.

Loss of system fluids may present with persistent or

recurrent incontinence. Fluid loss sites may include the

urethral cuff, any area of the connecting tubing, tubing

connections, the reservoir balloon, or rarely the control

pump. Once the fluid has been lost from the system, the

pumping characteristics will change until the pump is

empty. Simple abdominal radiography may exclude fluid

loss from the reservoir if the contrast solution is used as

the filling medium.

(C)

If isotonic sodium chloride solu-

tion is used as a fluid medium, the radiographic evaluation

does not help, because the silicone components are not

radiopaque. X-rays with insufflation-deflation are necessary

to assess the function of the sphincter. When the cuff is

closed, a contrast ring should be visible at the cuff site.

When the cuff is open, the pump and reservoir should con-

tain some fluid, and the cuff should have minimal fluid. If

radiographic contrast is absent, leakage has occurred.

(C)

When an isotonic (sodium chloride) solution is used as the

fluid medium, lower abdominal ultrasonography

(C)

non-contrasted computed tomography (CT) of the abdo-

men and pelvis can help to assess the volume in the balloon

and diagnose fluid loss.

(D)

However, the image will not

help to determine the exact location of the leak. During the

operative (revision) act, use of the electrical conductance

test (ohmmeter) assists in identifying the defective compo-

nent and the location of the leak.

(D)

If an ohmmeter

cannot be used to identify leakage location, the pressure in

the reservoir can be measured by connecting the tubes to

a pressure transducer or by aspirating and measuring the

volume of the balloon.

(C)

Surgical exploration is required

when fluid loss occurs. The “AUS Consensus Group” (2015)

recommends that the entire AUS device be removed if loss

of fluid is evident.

(D)

Nevertheless, studies have argued