RAMB - AGOSTO 2017

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Truzzi JC et al.
664 Rev Assoc Med Bras 2017; 63(8):664-680
GUIDELINES IN FOCUS
Male urinary incontinence: Artificial sphincter
Incontinência urinária masculina : Esfíncter artificial
Authorship: Brazilian Society of Urology (SBU)
Participants: José Carlos Truzzi 1, Carlos R. Sacomani 2, José Prezotti3, Antônio Silvinato4,
Wanderley Marques Bernardo4
Final draft: July 2017
1Sociedade Brasileira de Urologia, Universidade Federal de São Paulo
2Sociedade Brasileira de Urologia, A.C. Camargo Cancer Center
3Sociedade Brasileira de Urologia
4Associação Médica Brasileira (AMB)
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize
procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending
on the conditions and the clinical status of each patient.
Introduction
Patients with intrinsic sphincter deficiency include men
who have undergone retropubic radical prostatectomy
(including laparoscopic or robot-assisted radical prosta-
tectomy), radical perineal prostatectomy, or transurethral
resection of the prostate (TURP), patients with previous
pelvic trauma or history of pelvic radiation, women who
have undergone failed anti-incontinence procedures, and
patients with spinal cord injury, myelomeningocele or
other causes of neurogenic bladder, in which intrinsic
sphincter dysfunction may also exist. Urinary incontinence
after radical prostatectomy (UIRP) is the most common
indication for artificial urinary sphincter (AUS) implanta-
tion.1,2 The main etiology of UIRP is sphincter deficiency
in up to 90% of cases, either alone or combined with de-
trusor overactivity (DO).3
The placement of the artificial urinary sphincter should
be postponed for at least 6 months to 1 year, given that a
portion of the patients redevelop urinary continence in
this period. The AmericanMedical Systems 800 (AMS 800)
artificial urinary sphincter is the most widely-used device
and is considered the gold standard in the treatment of
urinary incontinence caused by intrinsic sphincter defi-
ciency, working based on hydraulic mechanics.4 The system
consists of a cuff connected to a reservoir balloon through
a pump. The three components are connected with torsion
resistant tubes.5 The sizes (lengths) of the cuffs range from
3.5 cm to 5.5 cm in 0.5 cm increments. The cuff can be
implanted in the bulbar urethra (most common) or in the
bladder neck. During rest, the reservoir pressure is trans-
mitted to the cuff, causing continence. Digital compression
of the pump promotes the transfer of liquid from the cuff
to the reservoir, relieving urethral compression and allow-
ing urination. After a period of time (3-5 minutes), the
liquid is transferred back into the cuff by compressing the
urethra or bladder neck, providing continence. The reser-
voir balloons come in three preset pressures: 51-60, 61-70,
71-80 cm of water; the lowest pressure required to close
the urethra should be used. Migration of components may
occur if the cuff is poorly dimensioned, if the pump or
balloon is not positioned correctly or if the pipe lengths
are incorrect.6
The standard placement of an AUS involves a small
incision made in the patient’s perineum or scrotum. Per-
ineal access is considered the most common; 7 however,
authors have also described the scrotal technique, thus,
the advantages and disadvantages of each should be con-
sidered by the surgeon.8
The “cuff,” which is the portion of the device that
surrounds and obstructs the urethra, is usually placed
directly around the urethra (i.e., the “standard” placement).
Another variation for cuff placement is the transcorporal
(TC) approach. This technique avoids the posterior ure-
thral dissection as well as of the corpora cavernosum. The
dorsal dissection plane for cuff placement is through the
septum of the corpora cavernosa from one side to the
other, resulting in a portion of the ventral tunica albu-
ginea acting as a cushion between the cuff and the dorsal