RAMB - AGOSTO 2017

ale

urinary

incontinence

: A

rtificial

sphincter

ssoc

ras

2017; 63(8):664-680

665

corpus spongiosum. The transcorporal placement of the

cuff was developed in an attempt to improve continence

in patients with recurrent incontinence secondary to

erosion, urethral atrophy, inadequate urethral coaptation,

after radiotherapy, or for patients undergoing revision,

in whommore proximal placement could not be achieved.

Proper patient counseling and careful attention to

intraoperative and postoperative details are important to

achieve good outcomes and high rates of patient satisfac-

tion. Several case series with long-term monitoring have

demonstrated efficacy of the AUS and patient satisfaction

even when surgical revisions are needed.

However, im-

plantation of the AUS is an invasive procedure that can

result in complications, such as postoperative infection,

urethral erosion and explantation.

Furthermore, previ-

ous urethral damage (such as failed surgical procedures,

urethral atrophy or history of pelvic radiotherapy) may

potentially result in technical difficulties and/or reduced

surgical efficacy. Urinary incontinence (UI) that can occur

after artificial urinary sphincter activation is classified as

either early (persistent) or late onset (recurrent).

In the

case of persistent UI, patients never regain urinary con-

tinence following AUS activation, with urinary loss often

similar to that experienced prior to implantation and

during the deactivation period. Persistent incontinence

is usually attributed to a surgical failure or inability to

identify detrusor overactivity or any other lower urinary

tract abnormality in the preoperative diagnostic evalua-

tion.

On the other hand, recurrent or late-onset UI gen-

erally occurs after several months or years after the AUS

implantation. There are several causes of persistent and/

or recurrent UI: unsuitable or accidental pump operation,

urinary tract infection (UTI) with detrusor overactivity,

overactive bladder, urethral atrophy, urethral erosion of

the cuff, inadequate cuff size, insufficient pressure of the

reservoir balloon, development (recurrence) of urethral

or bladder neck stenosis, as well as device failure with

fluid loss or obstruction of the control unit flow.

12,14,15

Revision rates between 8 and 45% have been reported due

to mechanical failure, while those derived from non-

mechanical complications such as erosion, urethral atro-

phy and infections are reported between 7 and 17%.

1,16-18

Certain complications have been described, with the

most significant being erosion and/or extrusion of the

sphincter, infection and urethral atrophy. In certain situ-

ations, there is a need to remove the device.

The follow-

ing are risk factors for complications: pelvic radiotherapy,

urethroplasty or any urethral manipulation and anteced-

ent erosion or infection in individuals previously submit-

ted to artificial sphincter implantation.

20-22

bjective

The objective of our evaluation is to establish guidelines

regarding the most important issues related to artificial

urinary sphincter implantation: the best practices in the

choice and preparation of the AMS 800 urinary sphinc-

ter components, preoperative care for patients with in-

dication of artificial sphincter, the best approach for

implantation of the artificial urinary sphincter (peri-

neal or transescrotal), to compare the transcorporal

placement of the cuff with the “standard” placement

(directly around the urethra), regarding efficacy and

safety, to assess the best conduct in the perioperative and

postoperative period of artificial urinary sphincter im-

plantation, to assess the best conduct in the management

of therapeutic failure (early or late onset urinary incon-

tinence) and to evaluate the best strategy against sus-

pected erosion or extrusion, infection and urethral at-

rophy, considering primary studies.

ethod

The initial eligibility criteria for studies were: PICO com-

ponents (

atient,

ntervention,

omparison,

utcome),

observational comparative studies (cohort and/or before-

-and-after), comparative experimental studies (clinical

trial), absence of restriction applied to the period of stud-

ies, no language restriction and availability of the full text.

Medline (via PubMed), Embase, Central (Cochrane),

Lilacs (via BVS) and manual search were the sources of

scientific information consulted in this study.

The search strategies used Medline – (Artificial Urinary

Sphincter OR Artificial Urinary Sphincters OR Artificial

Genitourinary Sphincter OR Artificial Genitourinary

Sphincters OR Artificial sphincter OR AMS 800 OR

AMS800); other computerized databases – ‘artificial AND

urinary AND sphincter’, and manual search – reference

within references, revisions and guidelines.

For study selection initially we searched by the title,

then by the abstract, and finally by its full text, the latter

being subject to critical evaluation and extraction of results

related to the outcomes.

The strength of the evidence from observational and

experimental studies was defined taking into account the

study design and corresponding bias risks, the results of

the analysis (magnitude and precision), relevance and

applicability (Oxford/GRADE).

23,24

The global evidence summary will be presented at the

end of the results. The global evidence summary will be

elaborated considering the evidence described.

The strength (Oxford/GRADE)

23,24

will be estimated

as 1b and 1c (grade A) or strong, and 2a, 2b and 2c (grade