ARTIFICIAL URINARY SPHINCTER SURGERY INFORMATION
What is it?
A silicone prosthesis inserted for the treatment of stress incontinence due to a failure of the urethral sphincter. The urethra is the tube from the bladder.
How does is work?
A balloon reservoir that holds fluid sits within the pelvis and keeps a cuff inflated around the urethra, preventing leakage of urine. A pump placed in the labia in women and scrotum in men is then operated to deflate the cuff when you want to empty your bladder. The cuff automatically re-inflates after 3-5 minutes.
What is done?
The procedure involves an abdominal incision. In men, when a cuff is placed around the ‘bulbar urethra’ a second incision in the perineum is required.
What tests might be required?
An examination, a urine test for infection, a cystoscopy (internal examination of the urethra and bladder), an ultrasound study to see if you empty your bladder completely when you pass urine and Fluoroscopic Urodynamic Studies to assess your bladder and urethral function. Any urine infection will need to be treated prior to surgery. If there is any infection or excoriation of the skin due to urine leakage this will also need to be treated first.
What are the alternatives?
There are non-operative treatments for stress incontinence such as bladder training and pelvic floor exercises. There are minor operations such as ‘injectables’. There are also other types of surgery for stress incontinence, like various sling procedures.
Am I suitable?
Manual dexterity is needed to operate the device. Suitable candidates also need to accept need for life long term follow up and the likelihood of further procedures to fix it, if the device fails.
Will it work and for how long?
Following this operation most patients with stress incontinence will be dry or significantly improved. 83% -95% patients are satisfied with the results. About 70% are completely dry, and 90% wear no more than one pad per day. There is a reasonably high risk (20-40%) of requiring further surgery for complications or revision of part of or the entire device at some stage.
What is the post-operative course?
The average hospital stay is 2-3 days. Initially after surgery an ice pack may be placed on the perineum when you are in recovery to reduce any swelling. A catheter is placed in the urethra during surgery and is removed the next day. The cuff is left deactivated for 6 weeks from surgery to allow healing to occur. This means when the catheter is removed you will probably be just as incontinent as you were prior to the operation. Some swelling in the area may result in a temporary improvement in your incontinence. If the swelling is marked and you are unable to pass any urine, (after your urologist has checked the pump has not accidentally been activated), a catheter will be passed intermittently to empty the bladder until the swelling subsides and you can pass urine again.
Antibiotics via a drip (cannula into a vein) are continued for 48 hours following surgery.
Following discharge oral antibiotic tablets are continued for 10-14 days.
It is usual to have some wound pain post-operatively but this mainly resolves by 6 weeks. Usually this is controlled with paracetamol. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day). Some patients describe occasional discomfort from their wounds for up to 12 months following surgery. Urinary urgency can occur as a new symptom in some patients after stress incontinence surgery. This is a sudden compelling desire to pass urine that can cause a need to urinate frequently and urgently and can result in urine leakage. If this occurs medication may be required to control this symptom.
Other Instructions for when you go home.
It takes about 4-6 weeks to return to normal activity. It is important to avoid any straining, heavy lifting or strenuous activity during this time. It is advised to avoid intercourse for 6 weeks from surgery, until after the sphincter is activated.
Pelvic Floor Exercises.
You should learn pelvic floor exercise and optimize your pelvic floor muscle strength prior to surgery. Pelvic floor exercises can cure stress incontinence in some people and avoid the need for surgery. Physiotherapists or continence nurses can assist with pelvic floor education and an exercise programme.
What are the early risks and complications?
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
- There is a small risk of injury to the urethra or bladder. If this occurs it will need to be repaired and a catheter placed for 7 – 10 days. Placement of the artificial sphincter will usually need to be abandoned and rescheduled for some weeks later after healing has occurred. The risk of injury resulting in worsening of your incontinence is very rare.
- Infection of the device is a very serious complication and although it can settle with antibiotics it will usually require returning to theatre to have the device removed. Fortunately this is uncommon, about 2-3% patients. Once removed for infection it takes 3-6 months to ensure complete resolution of the infection before a new device can be placed.
- There is a small risk of a urine infection, wound infection, wound breakdown, haematoma (collection of blood) or seroma (collection of fluid) post-operatively; 5-10%.
- Other rare complications include an abscess or a urinary fistula (leak).
- There is a small risk of bleeding requiring a blood transfusion.
- Bowel, nerve or vascular injuries are very rare.
- There are general medical risks of abdominal, cardiovascular (heart), and pulmonar (lung) illnesses; 2-5%. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke). There is a very small risk of death; 5 in 10,000. Complications that can occur later on, at any stage:
- There is a risk of mechanical failure of one of the component of the device. This may require part or all of it to be replaced. This happens in about one in every ten patients over 5 years.
- The cuff can erode through the tissues into the urethra which also requires replacement.
- Incontinence can occur due to shrinkage of the tissues in the urethra requiring either a new or second cuff to be placed.
- Overall 20-40% of patients require further surgery.
How long does the operation take?
About two hours.
You will be given a follow up appointment for 2 weeks from surgery and then at 6 weeks for pump activation.
If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Wound problems – infection, redness, swelling or breakdown
- Inability to pass urine
- Or any other significant trouble.
- After pump activation, if your incontinence returns at any stage you should arrange a review visit.
Things to remember.
When you open the cuff it automatically reinflates. This takes 3-5 mins. If some patients are slow to empty their bladder they might need a second ‘pumping’. If you don’t leak overnight you can deactivate the pump overnight which might reduce the risk of complications from the pressure of the cuff on the urethra. Most patients don’t bother to do this unless they have an increased risk of erosion. Remember the cuff must always be deflated before catheterisation. Life long follow-up at least once a year is advised for all patients with artificial urinary sphincters.
Men who have a ‘bulbar’ cuff placed should refrain from prolonged cycling or horse riding to prevent pressure on the cuff.
It is recommended to carry some identification with you informing persons you have and artificial urinary sphincter that requires deactivation prior to catheterisation. A MedicAlert Bracelet is recommended.
Female Patients/Pregnancy: A caesarean section is recommended to avoid pressure on the device during a vaginal delivery. Preferably a urologist should be present.
Version: V2, July 2013