Perineal Cuff Placement
In men, proximal bulbar urethral cuff placement is optimal. For cuff placement around the bulbous urethra, a midline perineal incision should be made over the bulbar urethra. The incision should allow for dissection and exposure of approximately 2 cm length of urethra (Fig. 45.4
). Great care must be taken in handling the corpus spongiosum, and every measure should be taken to prevent inadvertent entry into the urethral lumen. Electrocautery should be avoided in controlling bleeding associated with injuries to corpus spongiosum, which should be repaired with absorbable (4-0) suture instead.
The urethral mobilization should be carried out circumferentially by freeing the attachments of the dorsal aspect of the urethra from its adjacently associated corpora. Once the urethra is freely mobilized, the circumference can be accurately determined using the sizer/measuring tool provided in the AUS surgical kit. When placing the sphincter, the cuff size should be such that it is neither too tight nor too loose. One of the hints to ensure determine appropriate cuff size is that one should be able to easily insert the closed jaws of a right-angle clamp between the urethra and the sizer/cuff. It is important to select the cuff about 2 to 3 mm longer than the measured size to prevent a tight fitting cuff over the urethra, thereby preventing possible erosion. Usually, the most common size for a man undergoing a bulbar urethra AUS implant is 4.0 to 4.5 cm. More recently, 3.5-cm cuffs are starting to gain favor for both primary and revision AUS placement (7
After the cuff is placed, a 4- to 5-cm incision is made 2 to 3 cm above and just lateral to the pubic symphysis. This will be the planned reservoir (PRB) site. A transverse incision is then made in the fascia followed by blunt dissection to develop a space for the reservoir (PRB) between the transversalis fascia and
the retropubic space. The PRB is then placed in the space developed and inflated to 23 to 25 mL. Intraperitoneal placement of the PRB is not recommended because the PRB is functional only in the relatively closed retropubic space (personal communication, December 2014, American Medical Systems, Minnetonka, Minnesota). The type of the PRB chosen (61 to 70 cm H2O pressure versus 51 to 60 cm H2O pressure) depends on the indication for AUS placement. PRB with a higher pressure (71 to 80 cm H2
O) may be used with a bladder neck cuff. If AUS placement is for postprostatectomy incontinence, then a 61- to 70-cm H2O pressure PRB is acceptable. If the patient has any condition that may increase the chance of atrophy or erosion (such as prior radiation), a lower pressure PRB (51 to 60 cm of H2O pressure) is indicated. The tubing from the cuff will need to be passed into the suprapubic incision to be connected to the reservoir.
FIGURE 45.4 Various steps depicting perineal cuff placement in men. A: Perineal skin incision. B: Exposure of corpus spongiosum of the bulbar urethra after incising bulbospongiosus muscle. C: Circumferential mobilization of bulbar urethra. D: Measurement of the circumference of the bulbar urethra to select the appropriate cuff size. E: Appropriate size cuff placed around the proximal bulbar urethra. F: Clear and black tubing of the AMS 800. G: Filling of the reservoir with the “filling solution”. H: Subcuticular closure of the perineal skin incision.
Next, the control pump is placed in the subdartos pouch that is developed by spreading the ring clamp. The pump is placed in the right hemiscrotum in a right-handed person and vice versa. It is placed in the most anterior and dependent portion of the scrotum superficial enough with the deactivation button easily palpable. A path for the pump tubing is developed superiorly from the suprapubic incision into the perineal incision using a long clamp. It is important to secure the pump through the scrotal skin with a Babcock clamp to allow for optimal pump positioning while providing adequate tubing length until the end of the procedure.
Once all the tubing has been passed, excess tubing should be cut away and the remaining tubing should be connected using the connectors provided in the AUS accessory kit. Once all the tubing has been connected, the system should be cycled to test pump function. During the test, the urethral catheter should be removed, and urethroscopy should be used to visualize the cuff to assess for degree of occlusion of the activated cuff. Once the surgeon is satisfied, the cuff should be deactivated and remain deactivated for 4 to 6 weeks to allow for proper healing. Each layer of the wound is closed with absorbable sutures. The urethral catheter need not be reinserted unless there is suspicion regarding inadequate bladder emptying. The patient should be made aware that their incontinence will persist until the AUS is activated after an appropriate healing period. Patients can usually be discharged home 2 to 3 hours after surgery or on the first postoperative day with a 5- to7-day course of an oral antibiotic. The device is traditionally activated 6 weeks following implantation.
Transcorporeal Cuff Placement
This approach is usually reserved for patients who have had prior urethral erosion and/or an anatomically suboptimal urethra secondary to prior infected AUS or severe atrophy. Raj et al. (8
) noted that comorbidities such as hypertension, coronary artery disease, and prior radiation predisposed the patient to a higher chance of erosion. Given that a more proximal placement of an AUS is sometimes not feasible, a more distal approach has been evaluated but not without its own set of challenges. Wall thickness of the corpus spongiosum of the urethra becomes an issue, as it becomes thinner distal to the bulbar urethra, putting the urethra at a higher risk of erosion.
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