RAMB - AGOSTO 2017

ruzzi

674

ssoc

ras

2017; 63(8):664-680

that in specific cases when the leakage of a component can

be identified intraoperatively and the AUS has been placed

for a period of < 3 years, replacement of a single component

can be considered.

83,84

(C)

Urethral sub-cuff atrophy is defined as a progressive

loss of initial continence after AUS implantation in the

absence of erosion, mechanical malfunction or leakage and/

or bladder-related causes leading to worsening of urinary

continence.

(D)

Tissue atrophy results in a loss of urethral

compression and occlusion of the lumen. The progression

of incontinence increases slowly over months or years and

there is often a change in the number (increase) of pump

activations required to open the cuff.

(D)

A simple pelvic

X-ray will show more fluid in the cuff compared to an im-

mediate postoperative radiograph (if contrast fluid is used).

Urethroscopy discards erosion and confirms the diagnosis

of atrophy when poor coaptation of the mucosa at the cuff

level is observed with it fully inflated.

(D)

Urethral with-

drawal pressure profiling can be performed with the cuff

in inflated and deflated modes, although it is currently a

rarely used resource. A minimal pressure change between

the two modes suggests sub-cuff atrophy or sphincter dys-

function.

(D)

A more conservative initial therapeutic ap-

proach is preferred, such as reducing the cuff size or replac-

ing the position so that it is more proximal, whenever

possible.

17,85

(C)

Other procedures such as double-cuff

86-88

(C)

, transcorporal (TC) cuff placement

9,53,89

(C)

or higher

pressures in the reservoir may be considered. The literature

is not clear as to the best method for cuff revision. A his-

torical cohort study showed that the placement of a “dou-

ble-cuff” was more effective than either a “smaller size” (in

relation to mechanical failure; p=0.01) or compared to “re-

placement with a new location” (in relation to continence,

p=0.02).

(B)

Another historical cohort compared placement

of a double-cuff versus a single-cuff in patients with post-

-prostatectomy urinary incontinence as initial therapy. In a

long follow-up (74-58 months), the study did not show a

difference in the continence rate between the groups (NNT

= NS). However, the double-cuff group had a higher number

of complications requiring additional surgery (ARI = −0.53

to 0.008; NNH = NS; without statistical significance).

(B)

Global evidence summary

Inadequate AUS operation is the most common cause of

immediate UI post-activation.

(D)

In patients with overactive bladder and persistent UI,

when the pathophysiology remains doubtful, a urody-

namic assessment is indicated in order to guide treatment,

which should be similar to that of any patient with over-

active bladder.

(D)

If the patient does not show 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.

(C)

The diagnosis of a cuff with a loose fit can be per-

formed by reviewing the surgical notes, urodynamic study,

urethroscopic evaluation and retrograde perfusion sphinc-

terometry with a flexible cystoscope.

(C)

Simple abdominal radiography may exclude fluid loss

from the reservoir if the contrast solution is used as the

filling medium.

(C)

When an isotonic (sodium chloride) solution is used

as the fluid medium, lower abdominal ultrasonography

(C)

or non-contrasted computed tomography of the ab-

domen and pelvis can help to assess the volume in the

balloon and diagnose fluid loss.

(D)

The “AUS Consensus Group” (2015) recommends

that the entire AUS device be removed if a loss of fluid is

evident.

(D)

In specific cases, when the leakage of a component

can be identified intraoperatively and the AUS has been

placed for a period of < 3 years, replacement of a single

component can be considered.

(C)

Urethral sub-cuff atrophy is defined as a progressive

loss of initial continence after AUS implantation in the

absence of erosion, mechanical malfunction or leakage

and/or bladder-related causes leading to worsening of

urinary continence.

(D)

A simple pelvic X-ray will show more fluid in the cuff

compared to an immediate postoperative radiograph (if

contrast fluid is used). Urethroscopy can rule out erosion

and confirm the diagnosis of atrophy when poor coapta-

tion of the mucosa at the cuff level is observed with the

cuff fully inflated.

(D)

In atrophy, a more conservative initial therapeutic

approach is preferred, such as reducing the cuff size or

replacing the position to make it more proximal, when-

ever possible.

(C)

Other procedures such as a double-cuff

(C)

, transcorporal placement of the cuff

(C)

or higher

pressures in the reservoir may be considered.

7. C

omplications

The objective of our review is to evaluate the best strategy

against suspected erosion or extrusion, infection and

urethral atrophy.

Clinical question

What is the best strategy against suspected erosion or

extrusion and infection? This question was answered in

this evaluation using the PICOmethod, where the P stands