V12-06: Transcorporal Artificial Urinary Sphincter Placement in Patients with Prior Inflatable Penile Prosthesis Utilizing 6-ply Acellular Graft
Complex incontinent patients post prostatectomy, radiation, inflatable penile prosthesis (IPP), and multiple previous urethral surgeries are becoming more prevalent as prostate cancer survivorship improves. One of the most challenging clinical scenarios is an incontinent male with a high risk urethra and current IPP. Previous descriptions of utilizing a transcorporal approach by dissecting a plane between the IPP pseudocapsule and the tunica albuginea for artificial urinary sphincter (AUS) cuff placement have not proven clinically feasible. Herein we present a novel technique of transcorporal AUS placement utilizing a 6-ply acellular graft to provide a barrier between the AUS and IPP components.
Patient selection: Three patients have undergone this approach. All with history of prostatectomy, ≥3 previous urethral surgeries, current IPP, and subcuff atrophy after placement of a 3.5cm cuff. _x000D_ _x000D_ Operative Procedure: Cystoscopy is utilized to ensure good urethral integrity and rule out a urethral stricture. Throughout the procedure a modified washout protocol is utilized to minimize infection risk. The urethra is dissected and a Lonestar or Jordan Perineal Bookwalter is placed for optimal exposure. Next the Bovie settings are reduced to 25/25 and 2cm corporotomies are made on each side. Transcorporal urethral measurement is obtained. Sharp dissection is continued behind the urethra to allow for graft placement. The graft is sized 10% larger than measured to allow for shrinkage. The graft is sutured to the lateral edges of the corporotomies covering the IPP rear tip extenders. Next, the AUS cuff is placed between the urethra and the graft. The AUS components are connected in the usual fashion. Prior to closing the perineum, cystoscopy is utilized to confirm good urethral coaptation with activation and appropriate cuff cycling.
Several recent studies have demonstrated the efficacy and safety of a transcorporal AUS approach in both primary and salvage settings. This includes a substantially decreased risk of failure as compared to utilizing a 3.5cm cuff in high risk patients. In our current series, no perioperative complications have been encountered and the patients have done well post operatively.
Transcorporal AUS placement in a complex incontinent patient with current IPP utilizing a 6-ply acellular graft is an easy to learn technique that appears to be safe and effective. A larger patient cohort with follow-up data is needed to assess outcomes, rates of infection, and patient satisfaction.