Indicated for persisting bothersome stress incontinence despite maximal conservative measures.
AUS is the gold standard for moderate-severe stress urinary incontinence, whilst slings are a good alternative for mild-moderate stress incontinence.
Surgical intervention should be offered at 12 months post-operatively as incontinence is unlikely to improve significantly from there on.
Surgery can be discussed and offered from 6 months if there is significant incontinence with minimal improvement from conservative options – improvement from 6 to 12 months is possible but not very common.
Slings
Adjustable (ATOMS, Argus) vs non adjustable (AdVance)
Transobturator (AdVance, ATOMS) vs retropubic (Argus)
Proposed mechanism is repositioning and support of the proximal urethra, which increases the functional membranous urethral length and augments residual sphincter function.
Good candidates for sling:
- Mild to moderate incontinence – poorly defined – < 200 g pad weights
- Dry when supine or overnight
- No radiation
- Non obese (worse outcomes with increasing BMI)
- Unable to use AUS due to dexterity or cognition
- Good coaptation of sphincter
Efficacy:
- 50 – 60 % cure, 20 – 30 % better (“better, not perfect”)
- Long term durability unclear – seems durable at 2 years
Technique (AdVance):
- Must have negative pre operative urine and no skin infection
- Lithotomy position, ABx, prosthesis precautions, shave in theatre, alcoholic prep
- 16 Fr IDC, midline perineal incision centred on where catheter “disappears”, lone star retractor
- Through fascia and then through bulbospongiosus
- Mobilisation of corpus spongiosum to identify central tendon
- Stay suture on urethra at level of tendon, then dissect tendon off urethra
- Groin incisions – 1 – 2 cm below adductor longus tendon in the groin crease, lateral to ischiopubic ramus
- Use prepacked trochar – out to in at 45 degree angle – 2 pops – then rotate quarter turn and palpate on finger in perineum (with finger displacing and protecting urethra)
- Load the arm of the sling on the trochar and bring it bag out through groin incision
- Central portion of the mesh is fixed to the corpus spongiosum with 4 – 6 sutures with proximal aspect of the mesh secured to the previous marking stitch of the central tendon
- Tension the sling by pulling on the arms, aiming for 3 – 4 cm repositioning of the bulb, and remove the protective sheath
- Cystoscopy
- Closure
Post-op:
- IDC out day 1
- If fails TOV – recath and TOV 3-5 days – if fails again – ISC (+/- ‘squat’ to dislodge sling)
- Still unable to void 4-6 weeks -> consider division of one arm of sling
- Avoid squatting or any heavy lifting > 10 kg for 6 weeks
- No horse riding, bikes
- Oral antibiotics to go home
Complications:
- Urinary retention (up to 10 %)
- Perineal, scrotal, groin pain (about 5 %)
- Persistent severe groin pain suggests incorrect placement through adductor longus tendon or nerves
- Erosion 1 %
- De novo overactivity
Artificial urinary sphincter
Gold standard for male stress urinary incontinence.
3 piece device – cuff, control mechanism and pressure regulating balloon (PRB, reservoir).
Indications
- Suitable for essentially all comers with stress incontinence including large volume, post radiation, and with previous sling or other surgery
Contra-indications (relative)
- Untreated VUAS or urethral stricture – should be stable for 3 months and admit catheter
- Poor cognition or dexterity
- High pressure storage or poorly compliant bladder, which may endanger the upper tracts
- Obliterated retropubic/inguinal spaces
- Need for future transurethral surgery – e.g. recurrent bladder cancer, VUAS etc
Efficacy:
- 16 % revision at 2 years, 28 % revision at 5 years (generally 10 year device life expectancy)
- 60 – 90 % success rates (0- 1 pad)
- 85 % patient satisfaction with long term follow up to 10 years
Technique:
- Must have negative pre operative urine and no skin infection
- Lithotomy position, ABx, prosthesis precautions, shave in theatre, alcoholic prep
- 16 Fr IDC, midline perineal incision
- Through fascia and then through bulbospongiosus
- Circumferential dissection of muscle off spongiosum and spongiosum off cavernosa, able to get right angles behind urethra (bulbar urethra is dorsal within sponge, more at risk here)
- Continue dissection sharply until can pass sizer around bulbar urethra
- Cuff size chosen – 3.5 – 11 cm available (usually 4.5 cm) – and placed, rotated laterally off midline
- PRB can be placed via perineal, scrotal or inguinal incision – I usually do inguinal incision
- Incision down to EOA, opened in line of fibres
- Check which side patient prefers pre-operatively
- Develop extraperitoneal or retropubic pocket for PRB (can use nasal speculum)
- PRB placed (usually 61 – 70 cm) and filled with 23 mL saline or dilute contrast
- Subdartos pouch in scrotum – can be done bluntly with Rampleys from inguinal incision down to dependent scrotum – control pump placed with button superficial (can place Babcock externally to hold it in dependent portion)
- Tubing passed from perineal incision to inguinal incision and tubing connected through inguinal incision. Rubber shods throughout and flushing of tubing to ensure no air before connecting with crimping tool.
- Cycle prosthesis to ensure working OK
- EOA fascia closed with care to avoid prosthesis
- Bulbospongiosus and Colles’ closed
- Device left mostly open for 4-6 weeks
Post-op:
- Overnight admission, TOV in the morning
- Course of oral antibiotics
- Remains deactivated for 4 – 6 weeks
Variations:
- Double cuff may be used for severe incontinence – second cuff with Y connector
- Transcorporal cuff may be used in revision cases, significant radiation or previous atrophy
- Bladder neck cuff – more invasive abdominal dissection, useful for young neuropaths, usually requires large > 8 cm cuff
Complications:
Intra-operative:
- Urethral injury
- Close urethra with 4-0 PDS over catheter and abandon procedure – come back in 3 months
- Bladder injury
- Ensure bladder empty during procedure
- Close bladder if identified intra-op and abandon procedure or carry on but place PBR on other side?
Infection
- Signs/symptoms – erosion, persisting pain, pus, cellulitis, tenderness
- Mandates removal of all parts + washout + antibiotics
- Antibiotics alone generally not successful (biofilm produced by bug, fibrous capsule around device, relatively poor blood supply)
Erosion
- Presents with haematuria, pain, infection, recurrent UTIs
- Patient risk factors – infection, prior revision surgery, radiation, urethral surgery, catheters
- Surgical risk factors – urethral injury, undersized cuff
- Management – removal, catheter for a few weeks + urethrogram, consider new device after 6 months at different location
Urethral atrophy
- Normal consequence of long term compression
- Risk factors – undersized cuff, radiation
- Presents with worsening continence over time, with pale urethra during urethroscopy and incomplete coaptation when cycling
- Management – replace at new location, downsize to smaller cuff, transcorporal cuff
Managing new incontinence / troubleshooting AUS:
DDx:
- Mechanical – leak, loss of fluid
- Patient – not cycling correctly, accidental deactivation
- Iatrogenic – wrong size cuff
- Infection / erosion
- UTI
- De novo OAB
- Urethral stricture
Ix:
- Cycle the device
- Image the PRB checking for 23 mL
- Urine MCS
- Cystoscopy
ProACT
Non circumferential compression device – 2 balloons sit next to bladder neck, with intrascrotal port which can be used to adjust volume.
Reasonable cure (60 %) but also high complications (bladder and urethral injury, erosion, mechanical failure and migration), and even worse in setting of radiation therapy.
Treating climacturia
- Empty bladder prior to sex
- Condoms
- PFEs
- Surgery