Artificial Urinary Sphincter Placement for Male with Urinary Incontinence Following Radical Prostatectomy

Stress urinary incontinence (SUI) is a common condition in men due to decreased bladder outlet resistance. The most common cause of SUI in men is radical prostatectomy (RP), largely due to iatrogenic injury to the innervation of the internal and external urinary sphincters. While many patients elect for conservative management, those experiencing a significant detriment to their quality of life will elect to undergo some kind of intervention. The artificial urinary sphincter (AUS) is considered the gold standard treatment for men with mild-to-severe SUI. The AUS is a three-piece device, consisting of (1) the urethral cuff, (2) the control pump, and (3) the pressure regulating balloon. While multiple techniques have been described, a perineal incision is the most common approach. Dissection is carried down to bulbospongiosus muscle, which is divided and reflected off the proximal bulbar urethra to allow for cuff sizing. A second, lower abdominal incision is made to allow for placement of the pressure regulating balloon in the subrectus space along with creation of a subdartos scrotal pouch for placement of the pump. In this video, we present a case of a patient with moderate SUI following RP that was treated with placement of an AUS.

Artificial urinary sphincter; stress urinary incontinence; male urinary incontinence.

The artificial urinary sphincter (AUS) is widely considered the gold standard surgical treatment for men experiencing moderate to severe stress urinary incontinence (SUI). Consisting of a three-piece, fluid-filled device, this technology works to simulate native urinary sphincter function by compressing the urethra circumferentially and thereby reducing involuntary urinary leakage.^1,2 This device is patient-controlled and allows for volitional voiding but with an automatic reinflation, ultimately restoring continence.³ Recent data reveals a greater than 50% reduction in pad weight in nearly 95% of men at one year, with about 60% achieving complete continence.^4,5 This device is relatively durable, with approximately 64% of patients free from any mechanical failure 10 years postoperatively.² Common complications following AUS placement include urethral atrophy, infection, and urethral erosion, which ultimately may require urgent intervention.^2,3 While the AUS remains at the forefront of SUI management in men, careful patient selection and perioperative counseling are essential for successful patient outcomes.

This is a 63-year-old male with a history of grade group 2 pT2cN0M0 prostate cancer status post robotic-assisted laparoscopic radical prostatectomy (RP) two years prior with undetectable PSA who presented with moderate SUI. He reports using two pads per day that are moderately soaked when changed. He denies any urge urinary incontinence. He was referred for pelvic floor physical therapy without any significant improvement in his continence. He notes mild erectile dysfunction adequately treated with PDE-5 inhibitors. A flexible cystoscopy was performed which did not reveal any evidence of urethral stricture or bladder neck contractures. He was noted to have moderate coaptation when asked to volitionally squeeze his external urinary sphincter.

The patient was afebrile and had a normal heart rate and blood pressure. His phallus was circumcised with testicles descended bilaterally. There were no appreciable hernias bilaterally. No lesions were noted on the phallus or scrotum.

In males, SUI most commonly results from urethral sphincter compromise. This typically follows prostate-specific procedures, including RP or bladder outlet procedures, but SUI has been demonstrated in patients with a history of pelvic radiation or trauma. Some mild cases of SUI may self-resolve after one year post-treatment; however, men with persistent SUI after one year will experience stable or worsening symptoms, often necessitating treatment.⁶

Treatment options for male SUI largely focus around conservative therapies and surgical intervention. Behavioral modifications, including fluid restriction and management, timed voiding, Kegel exercises, as well as pelvic floor physical therapy are first-line measures.⁷ For men with refractory symptoms, there are several surgical options available including the AUS. Other options include male slings, which have demonstrated good results in non-radiated patients with mild-to-moderate SUI.⁶ Urethral bulking agents have also been used, but they have been shown to be much less effective and durable.⁶

The goal of surgical treatment for male SUI is to reduce their incontinence and improve their quality of life. Appropriate patient counseling is critical as the goal of surgical intervention is a significant reduction in their incontinence, understanding that complete restoration of their continence is unlikely.

SUI is a bothersome and increasingly common condition that affects many men across the United States annually. While many cases can be managed conservatively, men who face persistent bothersome and debilitating SUI have several surgical options available to them. Currently, the gold standard of treatment of male SUI is the AUS.

The traditional approach requires a perineal incision to access the proximal bulbar urethra along with a second inguinal or lower abdominal incision for placement of the pressure regulating balloon within the retroperitoneal space and the pump within a subdartos pouch.¹ A transscrotal approach has been described, allowing for single incision with placement of all components at once. While this provides a less morbid procedure for the patient, it often necessitates more distal placement of the cuff along the bulbar urethra, potentially reducing the rates of continence.⁸

In the case of this patient, he underwent RP for treatment of his prostate cancer, and fortunately his PSA has remained undetectable. He has developed persistent, moderate SUI now two years postoperatively that has been refractory to conservative measures. Reasonable treatment options for him include placement of a male sling versus an AUS, but given his degree of incontinence, the greatest improvement in his symptoms would likely be achieved with the AUS.

A key aspect to any prosthetic surgery, including placement of an AUS, remains sterility. Perioperatively, patients receive broad-spectrum IV antibiotics, thoroughly prepped and draped in a meticulous, sterile fashion. In the case of this patient, he received vancomycin and gentamicin for antibiotic coverage. While not applicable to this patient, in those that are diabetic it is crucial that they have adequate glycemic control prior to implantation as diabetes is a known risk factor for AUS revision.⁹ While there is no established cutoff, optimal glycemic control is advised.¹⁰

Following the procedure, the patient had his Foley catheter removed and was discharged on postoperative day one. He was seen approximately six weeks later in clinic for initial device activation. In clinic, he demonstrated appropriate manipulation and cycling of the device, being able to void well without issue. He was seen again four months later and he reported excellent continence without any issues cycling the device.

• 14-Fr Foley catheter.
• Bovie electrocautery.
• Yankauer suction tip.
• Lone Star retractor with hook appliers.
• #15 and #10 scalpel blades.
• Metzenbaum scissors.
• Adson forceps.
• DeBakey forceps.
• Tonsil hemostat.
• Babcock forceps.
• Right angle forceps.
• Vessel loop x1.
• 0.25-inch Penrose drain.
• Cuff sizer.
• 3-piece AUS device .
• Tunneling device.
• Shod clamps x4.
• Quick Connect Sutureless Window Connectors.
• Army-Navy retractors x2.
• Richardson retractors x2.
• Suture scissors.
• 2-0 Vicryl suture. 
• 3-0 Vicryl suture x2.
• 4-0 Monocryl suture x2.
• Dermabond surgical glue.

Nothing to disclose.

The patient referred to in this video article has given his informed consent to be filmed and is aware that information and images will be published online.