V11-06: Subcuff Capsulotomy and Pressure Regulating Balloon Interrogation: Dispelling Urethral Atrophy during Artificial Urinary Sphincter Revision for Recurrent Incontinence
Recurrent stress urinary incontinence (rSUI) after artificial urinary sphincter (AUS) placement can be a difficult problem for both patients and prosthetic urologists. In the absence of malfunction, the etiology is often assumed to be urethral atrophy. Urethral constriction by subcuff encapsulation, however, may preclude proper coaptation. We aimed to determine whether atrophy is a real phenomenon in selected patients and whether there is a component of PRB material fatigue.
We include three patient scenarios in this video. All patients had a history of prostate cancer treated with radical prostatectomy with subsequent AUS placement for SUI. We present a novel technique of subcuff capsule incision and pressure regulating balloon (PRB) interrogation. Urethral circumference is measured before and after ventral capsulotomy. PRB profiles are recorded and compared to initial manufacturer ratings.
Our first patient is a 67 year old male with rSUI who underwent prior AUS placement with a 4 cm cuff. Before and after capsulotomy, the urethral circumference measured 2.5 and 5 cm, respectively. A 5 cm cuff was placed. Our second patient is a 70 year old male with SUI who underwent prior AUS placement with a 4 cm cuff. Before and after capsulotomy, the urethral circumference measured 3 and 4 cm, respectively. A 4 cm cuff was placed. Our third patient is an 80 year old male with SUI who underwent prior tandem AUS cuff placement. Before capsulotomy, the urethral circumference measured less than 3 cm and, after, measured 4 cm, A 4 cm cuff was placed. Interrogation of the PRB in our first and second patient revealed a pressure of 59 and 51 cm H20, respectively, in balloons with 61-70 cm H20 initial manufacturer ratings.
The need for reoperation for rSUI is not uncommon and its etiology may be multi-factorial. Although a urethra may appear atrophied due to a constricted appearance below a previously placed AUS cuff, capsulotomy resulting in urethral recovery in real-time suggests otherwise. Our data are the first to demonstrate restoration of urethral circumference. The finding that a similarly sized cuff relative to that of initial placement can provide proper occlusion after capsulotomy suggests that revision surgery may be done more simply in the future. Our data suggest that pressure regulating balloon material fatigue may also play a role in rSUI.