Artificial Urinary Sphincter

The artificial urinary sphincter (AUS) is the gold-standard surgical treatment for moderate-to-severe male stress urinary incontinence, most often after prostatectomy. The device has three connected components — a urethral cuff, a pressure-regulating balloon, and a scrotal control pump — and successful implantation depends on meticulous urethral dissection, strict antimicrobial precautions, and careful patient counseling about device handling, especially deactivating the cuff before any catheterization.

Cuff Placement

1. Place patient in low lithotomy, ensure far enough down on bed for full perineal access, shave, prep, drape, give vancomycin + gentamicin or alternative, place capped catheter
2. Optional - cystoscopy prior to ensure no bladder neck contracture
3. Make midline perineal incision down to bulbospongiosus, place lone star retractor with hooks for retraction (use larger circle inferior)
4. Divide bulbospongiosus, then free up urethra using sharp dissection, ensure enough length proximal and distal, dissect until able to safely get right-angle clamp around urethra
5. Bring vessel loop around urethra to maintain access
6. Measure urethra to assess size, do not overly tighten
7. Bring right-angle behind urethra from same side as PRB placement, grasp cuff and pull through
8. Use rubbershod clamps to put cuff together without introducing air

Pressure Regulating Balloon (PRB) Placement

1. Choose suprapubic location within lateral portion of rectus, make transverse incision and cut down to anterior rectus fascia
2. Tag fascia with superior and inferior PDS stitches, then make transverse fascial incision between them
3. Develop submuscular space through this window, then place balloon and inflate with 20mL

Pump Placement

1. Place spongestick through PRB incision aiming inferiorly and laterally down to scrotum, once inside ipsilateral scrotum open and spread to create a space
2. Bring pump down into scrotum, ensure it does not retract

Connecting and Finishing

1. Develop space through PRB incision down to perineal incision, should be able to palpate small amount of tissue between fingers in both incisions
2. Use blunt needle passer to pass cuff tubing up to PRB incision site
3. Once tubing passed, start closing perineal incision - spongiosum, subcutaneous, then skin
4. Use connecting device to connect tubing together, trim redundant tubing prior if needed
5. Close PRB incision with subcutaneous and skin stitches
6. Apply dressing, leave foley x24hr

Surgery Tips

• Single vs tandem: single cuff via perineal approach is preferred, tandem cuff has increased explant rate (17% vs 4%)
• Urethral injury: can consider repair of small injury with absorbable suture and cuff placement at alternate location, otherwise abandon placement

Postoperative Recommendations

• Avoid sitting on hard objects for long periods of time
• Avoid cycling for 6 weeks, activate in office and ensure patient able to cycle
• Consider deactivating at night to provide urethral rest
• Deactivate AUS prior to catheter placement, minimize time with catheter

Complications

• Hematoma: most common complication
• Infection: 3-5%, usually within 2 months placement, assess for erosion via cystoscopy, wait 3+ months before reimplanting
• Urinary retention: may be due to urethral edema, ensure cuff deactivated, perform CIC with small catheter, consider SPT placement