Artificial urinary sphincter implantation

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the eleven steps, or use Back and Next. Open the Device panel to isolate a component, cycle the pump or read what can go wrong. Try a trigger to see a wrong move and its correction. Press Present for a full-screen run-through. Present this module

Operative steps

1. Orientation The patient is in lithotomy and you are looking up at the perineum from the foot of the table. Scrotum and penis lie above, the anus below, and the bulb sits under the pubic arch between them. One device, three spaces: the cuff on the bulbar urethra, the balloon behind the lower abdominal wall and the pump in the scrotum. Before you start, name proximal and distal along the urethra.
2. Perineal exposure Lift the scrotum forward and incise in the midline over the bulb with the blade. A ring retractor with hooks holds the skin edges; deepen through the fat until bulbospongiosus covers the field. Split the muscle along its midline raphe with the diathermy to reach the bulb beneath it.
3. The plane on the bulb Draw bulbospongiosus back and the corpus spongiosum lies beneath. This is the plane you are trying to develop: on the white tunica of the spongiosum, with the crura diverging either side. Before moving on, make sure you can identify the perineal body behind the bulb. A plane that starts to ooze has left the tunica.
   where it bites: a dissection outside the tunica opens the spongiosum, and the bleeding thins the bed the cuff must sit on.
4. Circumferential mobilisation A right-angle clamp passed in the dorsal plane, between spongiosum and corpora, frees the proximal bulbar urethra all round, on the tunica, where the crura separate. A loop follows it through once the plane is complete. Release only what the cuff needs.
   where it bites: a long bare segment may lose its blood supply, and it is the segment the cuff must heal onto.
5. Sizing Pass the sizer round the urethra without compressing it. That free reading chooses the cuff. The ContiRegular® cuff comes in twenty sizes from 3.5 to 13.0 cm, in 0.25 cm steps at the small end. A reading taken under squeeze is too small.
   where it bites: an undersized cuff is too tight on the urethra, and a tight cuff risks erosion.
6. Place the ContiRegular cuff Wrap the ContiRegular® Occlusive Cuff round the proximal bulbar urethra, where the corpora cavernosa separate. How it closes follows the manufacturer's instructions, not this model. Its tubing leaves the cuff laterally, here on the left, toward the scrotum. The HydroShield™ coating is slippery when wet; the dipping solution is the surgeon's choice.
   where it bites: a cuff placed distally sits on thin spongiosum beyond the crura, away from the site the manufacturer names.
7. Pressure Regulating Balloon Through a separate small transverse lower abdominal incision the muscle is held apart with retractor blades and a pocket is made in the prevesical space, the space of Retzius, behind the abdominal wall. The ContiClassic® Pressure Regulating Balloon is carried in collapsed on a forceps and filled there with sterile isotonic saline, as the instructions for use state; the fill volume is not stated in the instructions for use and is not taught here. It comes in five labelled ranges from 40-49 to 80-89 cmH2O. Which range suits a patient is the surgeon's decision and is not taught here. The fascia is closed round the tubing where it leaves.
   where it bites: a balloon in the wrong position can migrate, and the manufacturer names erosion of the balloon into the bladder.
8. Control Pump A long clamp from the abdominal wound opens a dependent pouch low in the scrotum, in front of the left testis. The ContiClassic® Control Pump follows it down the same tunnel and sits there with its deactivation button facing forward. He must be able to find it and squeeze it through the scrotal skin. A pump left high beside the cord may be hard to use.
   where it bites: a wrong pump position is one of the causes of migration the manufacturer names, and the pump can erode through the scrotum.
9. Tunnel and connect A clamp leads each line to the pump close to the pubis, one from the cuff and one from the balloon. Cut each to length, let the excess go, flush the ends and join them with EasyClick™ connectors, which need no assembly tool; the rubber-shod clamps come off last. No tension, no redundant loops. The tubing is reinforced against kinking, but a line cut to the wrong length can still kink.
   where it bites: wrong tubing length is a cause of migration the manufacturer names.
10. System check Squeeze the pump: fluid leaves the cuff and passes to the balloon, and the cuff opens. Over the next two minutes the cuff gradually closes again. Then cycle the cuff open and press the deactivation button. Only with the cuff open and the device deactivated does any instrument pass the urethra: the catheter comes out and a flexible scope goes up to the cuff segment to confirm the mucosa is intact and there is no injury. The scope is withdrawn below the cuff before the button is released, and the lumen is watched coapting as the cuff refills. Check every connection before you close.
    where it bites: a scope or catheter passed through a closed cuff damages the urethra or the device; the cuff is deflated and the device deactivated first.
11. Deactivate and close Squeeze once more to open the cuff, then press the deactivation button so it stays open. Hooks off; bulbospongiosus closed over the cuff with a running stitch, then the skin, then the abdominal wound, all with the device off. The instructions for use keep the device deactivated for four to six weeks after implantation, until scrotal swelling and pain have settled; activation follows in clinic by local protocol. Until then, and at any time after, no catheter or instrument passes the urethra until the cuff is deflated and the device deactivated.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Stress urinary incontinence in men and women. Not a workplace-based assessment and not evidence of competence.