UROLOGICAL SURVEY   ( Download pdf )

 

FEMALE UROLOGY

Outcome of the Artificial Urinary Sphincter in Female Patients
Thomas K, Venn SN, Mundy AR
St. George’s Hospital and Institute of Urology and Nephrology, London, and St. Richard’s Hospital, Chichester, United Kingdom
J Urol. 2002; 167:1720-2

  • Purpose: We reviewed the outcome in female patients at our unit in whom an artificial urinary sphincter was inserted.
  • Materials and Methods: We reviewed notes on 68 patients and mailed a questionnaire to those without recent followup.
  • Results: Median time since insertion was 12 years. Overall 25 patients (37%) had the original artificial urinary sphincter in situ and were dry at a median followup of 7 years. The artificial urinary sphincter was replaced for loss of function in 12 patients, of whom 11 were dry with the replaced device. The device was removed for erosion or infection in 31 patients, of whom 19 underwent successful replacement or were continent after removal. Overall 55 of 68 patients (81%) were continent. Those with neuropathic bladder dysfunction achieved a continence rate of greater than 90%, although half required sphincter removal initially. When the indication for insertion was stress incontinence, 70% of the patients had the original or a replaced artificial urinary sphincter in situ and 82% were continent. All patients with previous pelvic irradiation had the sphincter removed and urinary diversion was done.
  • Conclusions: The overall continence rate in female patients after insertion of an artificial urinary sphincter is satisfactory. A satisfactory outcome was achieved in terms of stress incontinence and we would recommend an artificial urinary sphincter after an adequate anti-stress incontinence operation fails. Continence in patients with neuropathic bladder dysfunction is excellent and the artificial urinary sphincter should be considered first line treatment in this group, although the risk of revision surgery is high. Pelvic irradiation is a contraindication to the artificial urinary sphincter in female patients.

  • Editorial Comment
    The authors review the outcome of the use of artificial urinary sphincter in the female patient. This manuscript is important secondary to the volume of patients reviewed (n=68), as well as their observation of the role of pelvic radiation pre-operatively, and its use in the neuropathic population. This is a valuable review, since the use of the artificial urinary sphincter in women is still not as common as its use in the male incontinent patient population. The artificial urinary sphincter in women differs from the traditional urethropexy or suburethral sling in that it tends to not elevate the bladder neck to a high retropubic position, nor to provide a backboard of urethral support; it attempts to mimic the sphincter mechanism of the urethra with a circumferential compression (1). Though in this study the patients had their device placed transabdominally, transvaginal approach may be used as well (2). Of note, in Appell’s transvaginal series, no woman suffered from any erosion. Findings of this paper included that the observation of the risk of erosion in the neuropathic bladder population is approximately 50%, but the authors did use a 71-80cm water pressure reservoir, which is somewhat higher than the traditional 61-70cm pressure reservoir used in patients treated for male post-prostatectomy incontinence. In addition, the investigators were able to identify pelvic irradiation as a significant risk factor to morbidity with the artificial urinary sphincter placement in the female population. At the time of placement of an artificial urinary sphincter in the female, bladder, urethral, or vaginal injury should not lead to abandonment of the procedure. The injured area should be identified and closed in layers, if possible with absorbable suture (3).
    Of interest would have been the authors’ comments on the impact of the artificial urinary sphincter on female sexuality, fecundity, and parturition. The placement of artificial urinary sphincter in the woman should not interfere with the sexual aspect of her life, or with potential fertility (2,4). If the female patient should become pregnant, consideration should be given towards deactivation in the third trimester, to diminish the excessive pressure on the cuff and bladder neck (5). Whether to utilize a vaginal delivery or Cesarean section at the time of delivery, can be left to the discretion of the obstetrician, with both methods having been described in the literature (4,5).
    With regards to these authors study, facets which may warrant further exploration include review of potential complications experienced by those patients who underwent enterocystoplasty. It has been found that approximately 30% of patients with mild meningocele and an artificial urinary sphincter will need an augmentation enterocystoplasty (6,7). A point of debate in the literature is whether the artificial urinary sphincter should be placed at the time of the augmentation, or initially in a staged manner (6,8). In addition, another point to review, which may further add to this excellent article, is the rate of clean intermittent catheterization experienced by the patients.
    The authors should be applauded for their adding to the urologic literature of their findings in female patients with the artificial urinary sphincter. Their experience with pelvic irradiation and later, artificial urinary sphincter, may help the reader avoid potential complications with this population.

References
1. Light JK, Scott FB: Management of urinary incontinence in women with the artificial urinary sphincter. J Urol. 1985; 134:476-8.
2. Appell RA: Techniques and results in the implantation of the artificial urinary sphincter in women with type III stress urinary incontinence by a vaginal approach. Neurourol Urodyn. 1988; 7:613.
3. Salisz JA, Diokno AC: The management of injuries to the urethra, bladder or vagina encountered during difficult placement of the artificial urinary sphincter in the female patient. J Urol. 1992; 148:1528-30.
4. Fishman IJ: Female Incontinence and the Artificial Urinary Sphincter. In: Seidmon EJ and Hanno PM (eds.), Current Urologic Therapy. Philadelphia, WB Saunders, 3rd ed.,1994, pp 312-315.
5. Fishman IJ, Scott FB: Pregnancy in patients with the artificial urinary sphincter. J Urol. 1993; 150:340-1.
6. Gonzalez R, Merino FG, Vaughn M: Long-term results of the artificial urinary sphincter in male patients with neurogenic bladder. J Urol. 1995; 154:769-0.
7. de Badiola FI, Castro-Diaz D, Hart-Austin C, Gonzalez R: Influence of preoperative bladder capacity and compliance on the outcome of artificial urinary sphincter implantation in patients with neurogenic sphincter incompetence. J Urol. 1992; 148:1493-5.
8. Stawbridge LR, Kramer SA, Castillo OA, Barret DM: Augmentation cystoplasty and the artificial genitourinary sphincter. J Urol. 1989; 142:297-301.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA