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M
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urinary
incontinence
: A
rtificial
sphincter
R
ev
A
ssoc
M
ed
B
ras
2017; 63(8):664-680
675
for the patient with urinary incontinence due to sphinc-
ter deficiency; I for intervention with an artificial urinary
sphincter; and O for urethral erosion and infection. Based
on the structured question, we identified the keywords
used as the basis for searching for evidence in the data-
bases and after the eligibility criteria (inclusion and exclu-
sion), which were selected to answer the clinical question
(Annex VII).
Results
The usual procedure in the treatment of urethral erosion
consists of the surgical removal of the cuff, plus passage
of a Foley catheter or suprapubic cystostomy.
19,92
(B)
However, removal of the remaining components is not
mandatory, as long as they are not infected. Although
the risks and benefits of complete removal have been
debated for a long time, acceptance of the maintenance
of certain components has been growing.
93
(C)
A retro-
spective observational study that analyzed outcomes
related to individuals submitted to the installation of
urological prostheses in five-year period (penile prosthe-
ses installed in 300 individuals and artificial urethral
sphincter in 251) verified that among the 120 individu-
als who required surgical re-attachment due to persistent
urinary incontinence, erosion, urethral atrophy, mal-
functioning of the prosthesis and pain, 45% of cases (n
= 55) did not require complete removal of all compo-
nents.
94
(C)
The regulatory balloon, normally placed in
the suprapubic region, can be abandoned, provided there
is no infection. The pump, however, is commonly re-
moved together with the cuff and connecting tubes
between them. Another retrospective study that analyzed
10 years of experience with artificial sphincter implanta-
tion found that 31.6% of patients (n = 25) required at
least one additional procedure because of urethral atro-
phy (22.8%) or erosion or infection (8.9%).
95
(C)
In this
analysis, two individuals submitted to the artificial
sphincter implant were monitored clinically for several
years even after identification of the erosion of the cuff.
In this case, both refused surgical treatment and re-
mained continent and uninfected despite chronic erosion
for more than five years (15 and 5 years, respectively).
95
(C)
The maintenance of the cuff is an exception and is
not supported in the literature. The usual treatment is
removal of the eroded urethral cuff. Urethral erosion
may result in stenosis at the affected site and require
additional procedures to correct it. Authors have re-
ported that more than 80% of the patients presenting
erosion followed by removal of the cuff developed ste-
nosis of the urethra.
96
(C)
Other authors have described
urethroplasty at the same time as removal of the device
to prevent subsequent stenosis.
97
(C)
With regard to infection, this may occur in the periop-
erative period or even years after implantation of the de-
vice.
37
(B)
Infection rates in contemporary series have been
reported between 1 and 8%, which may be less than 2% in
series involving a large number of patients.
17,31,59,63,98
(C)
37
(B)
Gram-positive microorganisms such as
Staphylococcus
aureus
and
Staphylococcus epidermidis
are most commonly
associated with infection, and Gram-negative bacteria
may be identified, such as
Pseudomonas aeruginosa
and
Escherichia coli.
67
(C)
In the presence of superficial infection,
oral or intravenous antibiotic treatment may be the ap-
proach of choice. However, if there is any doubt about
the device’s impairment, it should be removed, given the
possibility of biofilm formation on the prosthesis.
67
(D)
Global evidence summary
The recommended conduct for urethral erosion is re-
moval of the cuff and preferably of the other components.
In selected cases, parts of the device may be retained. Do
not remove the eroded cuff is an exception. In the pres-
ence of superficial infection, clinical treatment may ini-
tially be attempted. However, the recommended treatment
in most cases is removal of the device, providing coverage
for Gram-positive and Gram-negative bacteria.
Annex I
AMS 800 M
odel
Clinical question
What conduct should be adopted in the choice and prep-
aration of the components of the artificial urinary sphinc-
ter model AMS 800?
Structured question (PICO)
•
•
P
atient – Patients with urinary incontinence due to
sphincter deficiency.
•
•
I
ntervention – Implantation of the AUSmodel AMS 800.
•
•
C
omparison – Different components and preparation
of such (cuff and balloon).
•
•
O
utcome – Control of incontinence and complications.
Data extraction
The results obtained from the studies included were related
to the number of patients who obtained benefit or harm
with different components (e.g. better cuff size) or prepara-
tion (better balloon pressure and filling liquid of the system).