1. MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER COMPLICATIONS

2.  78 yo male c ISD following open radical prostatectomy. 3-5 pads per day  AMS tandem cuff AUS implanted in 2008  Very satisfied with results, able to return to active life of fishing and golfing 5-7 days weekly  PMH: Myesthenia Gravis 2010; h/o Prostate Cancer; Depression  PSH: Open Radical Prostatectomy; Tandem Cuff AUS; Right Inguinal Hernia Repair 9/2011  Meds: Cellcept & Zoloft  Social: Retired; Non Smoker; Avid golfer & fisher; Wife Retired OR Nurse CASE

3.  October 2011: Presented to ED with a red edematous scrotum & difficulty manipulating scrotal pump. Symptoms developed over 2-3 week period  Denies pain, dysuria, hematuria, fever or chills  Physical Exam  AVSS  Nl Penis  R hemiscrotum mild erythema/induration/pump fixed to scrotal wall/skin dimpled/minimal TTP  WBC 12 UA not sent by ED  Antibiotics  US demonstrating simple fluid collection surrounding scrotal pump CASE CONTINUED

4.  Labs - WBC 12; UA not sent by ED  Imaging  Scrotal US as outpatient  Cystoscopy -> no urethral erosion/no bladder neck contracture  The patient was diagnosed with an infected AUS and taken to operating room on 11/28/11 CASE CONTINUED

5.  Scrotal Exploration/Explant of Scrotal Pump/Cystoscopy/Placement of Foley Catheter  Indurated/inflammatory rind  Clear fluid surrounding pump – cultured  Urethral cuffs intact without evidence of infection  Deactivation of system in deflated position -> Rubber shad connections -> pump removed -> tubing kinked and tied off  Post Operative Course  PICC Line: Ceftriaxone/Vancomycin  Foley D/C in office POD#2  Subsequent cultures all negative OR 11/28/2011

6.  12/3/11: Re-presents to the ED with clear liquid drainage from scrotal incision. Catheter removed day prior. No F/C, N/V. No SP TTP  Difficult Foley  Pollack/sensor wire -> 12F Foley over wire  Labs: Body fluid Cr collected but not sent by ED  Outpatient urethrogram normal – no extravasation  Catheter removed, patient represented to Memorial c urinary retention  Punch SPT placed 12/8/11 CASE CONTINUED

7.  First developed and implanted in 1974  Over 20,000 devices implanted  Main indications  ISD – post prostatectomy  Neurogenic bladder dysfuntion AUS INDICATIONS & CONTRAINDICATIONS

8. ComponentsOutcomes  Urinary continence achieved 73% (range 61%-96%)  Post-prostatectomy continence ≈ 90% OUTCOMES OF AUS

9.  Urinary Retention  Urethral Atrophy  Erosion –5 – 15%  Early Infection:  1-3% general  10% pelvic radiation or reoperation (Montague, 1992)  Mechanical Failure  3% device malfunction  Less common with newer AMS models AUS COMPLICATIONS

10.  Make sure cuff is deflated and pump deactivated  US or Floroscopic guided Suprapubic Tube Placement  Prevent damage to pre-pubic balloon pump  Prevent urethral erosion  Retention lasting > 2 weeks may warrant reoperation for cuff upsizing URINARY RETENTION

11.  Most common reason of AUS reoperation  Presents with painless increased leakage of urine  Chronic compression of spongy tissue under occlusive cuff  More common in patients with pelvic radiation  Treatment: Re-Operation  Cuff Downsizing  Move cuff to more proximal or distal location  Tandem Cuff Insertion URETHRAL ATROPHY

12.  5% overall incidence (less common now than in past)  Risk Factors*: HTN/CAD/Pelvic Radiation/AUS Revision  Presentation: UTI/Pain/Fever/Scrotal Swelling/Fistula  Treatment:  Explant of all components  Urethral Catheter 2-4 weeks or until no extravasation on urethragram  Reimplantation after 3-6 months. EROSION Hussain, 2005 Martins, 1995 Walsh, 2002 * Kim, 2008 * Gohma, 2002

13.  Deactivation  Deactivation for 6 weeks decreased erosion from 18% to 1.3%  Reimplant following erosion  8.7% - 35% recurrent erosion  Nightly deactivation recommended  Transcoporal cuff may decrease risk further EROSION Motley & Barret, 1990 Raj, 2006

14.  Early mechanical failure rates 12%  Decreased to 7.6% following introduction of narrow backed cuff and improvement in cuff composition that decreased cuff leak  Actual device failure currently quoted at only 3%  Failures include  kinking of tubing  Early experience with large cuff sizes (≥5.5cm) and improper balloon selection MECHANICAL FAILURE

15.  1-3% rate after implant  RR increased in individuals with pelvic radiation/reoperation  Presentation: Scrotal pain, fixed scrotal pump, erythema  Gross Purulence/Sepsis/Bacteremia/UTI/Ketoacidosis/Immunosupp ression*  Explant of AUS  Is there a role for immediate salvage re implant operation for infected prosthesis? INFECTION Hussain, 2005 Martins, 1995 Walsh, 2002 Kim, 2008

16. SALVAGE OF INFECTED AUS  8 patients, 9 salvage procedures  5/8 patients Tandem Cuff AUS only  3/8 patients AUS + Penile Prosthesis  Follow-up 5-66 mo (mean 33mo)  87% success rate (1 patient required reoperation and removal for erosion)

17. SALVAGE OF INFECTED AUS 7 solution irrigation

18. MANAGEMENT OF COMMON POST OPERATIVE ARTIFICIAL URINARY SPHINCTER COMPLICATIONS