PERIURETHRAL
CONSTRICTOR IN THE TREATMENT OF
NEUROGENIC URINARY INCONTINENCE: THE TEST OF TIME
SALVADOR VILAR CORREIA LIMA, FABIO DE OLIVEIRA VILAR, LUIZ ALBERTO P. ARAÚJO
General Hospital, Federal University of Pernambuco and Manoel Almeida Children’s Hospital, Recife, PE, Brazil
ABSTRACT
Objective:
To present the long-term follow-up of patients using the periurethral
constrictor in the treatment of urinary incontinence of neurologic origin.
Patients and Methods: Twenty-four patients
suffering from neurogenic bladder secondary to myelomeningocele were prospectively
studied during the last 7 years to test the efficacy and safety of the
periurethral constrictor in controlling urinary incontinence. The device
was implanted around the bladder neck in 23 cases and around the bulbous
urethra in 1. Twenty-one patients had bladder augmentation with demucosalized
colon at the same time. Patients went to a urologic work-up that included
urinalysis, ultrasonography, cystography and urodynamics. These tests
were repeated at 3 months intervals during the first year and yearly thereafter.
A good result was considered if the patient kept the device in situ and
achieved continence.
Results: The follow-up ranged from 1 to
84 months with a mean of 50.9 and a median of 57. Twenty-one patients
still have the device in place and preserve continence. The bladder is
emptied by clean intermittent catheterization. Three patients had the
device extracted due to erosion and infection. The result was considered
as good in 87.5% of cases.
Conclusion: The prospective analysis of
the present series shows that the periurethral constrictor is a safe method
of treatment in patients suffering from urinary incontinence of neurogenic
origin when studied in long-term follow-up.
Key words:
incontinence, urethra, urinary sphincter, artificial, neurogenic bladder,
prostheses, implants
Braz J Urol, 26: 415-417, 2000
INTRODUCTION
The
mechanism of voiding involves a complex neuromuscular apparatus, which
needs to work in perfect synchronism in order to allow bladder filling
and emptying at appropriate time and place. Lesions that interfere with
this mechanism lead to impairment of vesico sphincteric function, as well
as deterioration of the upper urinary tract. Myelomeningocele is the most
frequent cause of lesion of the neurologic pathway involved in micturition.
The majority of patients born with this lesion have significant impairment
of the continence mechanism.
Clean
intermittent catheterization (CIC) has proven to be the safest method
for satisfactory bladder emptying in these cases. Different surgical procedures
have been proposed to promote continence that included the enhancement
of urethral resistance utilizing the bladder wall (1-7) or creating abdominal
urethras (8). The AS-800 artificial sphincter is the most popular device
in use for over 20 years (9).
The
present study aims to present the long-term follow-up of patients using
a periurethral constrictor in the treatment of urinary incontinence of
neurologic origin.
PATIENTS AND METHODS
Twenty-four patients suffering from neurogenic bladder secondary to myelomeningocele were prospectively studied during the last 7 years to test the efficacy and safety of the periurethral constrictor (manufactured by Silimed, RJ, Brazil) in controlling urinary incontinence. Fourteen patients were males and 10 were females. The age ranged from 5 to 42 years (Table-1). The device was implanted around the bladder neck in 23 cases (Figure-1A). In 1 case, the implantation was around the bulbous urethra (Figure-1B). Details of the device and the surgical technique have been described previously (10). Twenty-one patients had bladder augmentation with demucosalized colon at the same time.
| Figure 1 - Schematic drawings of the device implantation. | |
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|
 |
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Preoperatively patients went to a urologic work-up that included urinalysis, ultrasonography, cystography and urodynamics. These tests were repeated at 3 months intervals during the first year and yearly thereafter. A good result was considered if the patient kept the device in situ and achieved continence. The device was activated 6 to 8 weeks after the implantation. The port located at the subcutaneous space is punctured and saline is injected until the pressure inside the cuff reaches 70 cm of water (Figure-2).
 |
|
RESULTS
The follow-up ranged from 1 to 84 months with a mean of 50.7 and a median of 57 (Table-1). Twenty-one patients still have the device in place and preserve continence. Two patients didn’t need to activate the device. In 2 cases, the subcutaneous port was exposed due to skin erosion. The tube was ligated by a second incision without interference with the result. The bladder is emptied by clean intermittent catheterization. Three patients had the device extracted due to erosion and infection during this first year after the implantation. The result was considered as success in 87.5% of cases.
DISCUSSION
It
is well known that the AS-800 artificial sphincter offers satisfactory
results in treating urinary incontinence of various etiologies. There
is an over 10 years experience accumulated in the literature with the
use of this device in children (11). The complexity of this 3-piece device
with connections and a variety of cuff sizes and especially the high cost
imposes some restrictions to its use. Patients with some disabilities
have difficulties in emptying the cuff by pressing the control pump. In
a similar study published by Simeoni et al. (12) they studied 87 patients
with neurogenic bladder that had an AS-800 artificial sphincter implanted.
The overall success rate with a mean follow-up of 60.9 months was 76.6%.
The
periurethral constrictor works by enhancing the urethral resistance allowing
catheterization without the need for emptying the cuff. It can be deactivated,
underactivated or reactivated at any time. Although this represents a
small series, a mean follow-up of over 4 years was observed for the whole
group and more than a half was followed-up for over 5 years. From these
observations, we suggest that this device represents a safe alternative
in the treatment of patients with incontinence of neurogenic etiology.
________________________
Dr. R. Glasner drew Figure-1
REFERENCES
- Young HH: An operation for the cure of incontinence associated with epispadias. J Urol, 7: 1, 1922.
- Lapides J, Diokno AC, Silber AJ, Lowe BS: Clean intermittent self-catheterization in the treatment of urinary tract disease. J Urol, 107: 458-461, 1972.
- Dees JE: Epispadias with incontinence in the male. Surgery, 12: 621-630, 1942.
- Leadbetter Jr. GW: Surgical correction of total urinary incontinence. J Urol, 91: 261-266, 1964.
- Tanagho EA: Bladder neck reconstruction for total urinary incontinence: 10 years experience. J Urol, 125: 321-326, 1972.
- Kropp KA, Angwafo FF: Urethral lengthening and reimplantation for neurogenic incontinence in children. J Urol, 135: 533-536, 1986.
- Pippi Salle JL, McLorie GA, Bägli, DJ, Khoury AE: Urethral lengthening with anterior bladder wall flap (Pippi Salle procedure): modifications and extended indications of the technique. J Urol, 158: 585-590, 1997.
- Mitrofanoff P: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir Pediatr, 21: 297-305, 1980.
- Scott FB, Bradley WB, Timm GW: Treatment of urinary incontinence by an implantable prosthetic urinary sphincter. J Urol, 112: 75-80, 1974.
- Lima SVC, Araújo LAP, Vilar FO: Combined use of enterocystoplasty and a new type of artificial sphincter in the treatment of urinary incontinence. J Urol, 156: 622-625, 1996.
- Levesque PE, Bauer SB, Atala A. Ten-year experience with the artificial urinary sphincter in children. J Urol, 156: 625-628, 1996.
- Simeoni J, Guys JM, Mollard P. Artificial urinary sphincter implantation for neurogenic bladder: a multi-institutional study in 107 children. Br J Urol, 78: 287-293, 1996.
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Received: August 6, 2000
Accepted: August 20, 2000
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Correspondence address:
Salvador Vilar C. Lima
Rua Jener de Souza, 629
Recife, PE, 52010-130, Brazil
Fax: + + (55) (81) 222-0747