Evaluation and surgical management of intrinsic sphincter deficiency after radical prostatectomy

Abstract

Urinary incontinence following prostatectomy is usually due to intrinsic sphincter deficiency and is often referred to as post-prostatectomy incontinence (PPI). The male sling is an effective minimally invasive procedure for low volume PPI. Although the male sling procedure is becoming increasingly popular, the artificial urinary sphincter (AUS) remains the gold standard. Placement of the AUS cuff using the transcorporal technique salvages patients with urethral atrophy as well as prior AUS erosion or infection. As the surgical options for PPI expand, it is important to analyze the outcomes with contemporary surgical techniques and to develop an algorithm for procedure selection.

Figure 1

Urethral dissection. A midline scrotal incision is made and the dissection is deepened to expose the urethra and corporal bodies.

Figure 2

Corporal dissection. (A) A 2-cm longitudinal incision is made in the tunica albuginea of each corporal body 5 mm from the urethra and deepened until spongy tissue is encountered. (B) A tunnel is created between the corporal bodies with little difficulty.

Figure 3

Reconstitution of the corporal bodies. Two mattress sutures of 2-0 polyglycolic acid are used to close the lateral margins of the corpora dorsal to the cuff. (A) Each suture is placed through the lateral edge of one corpora. (B) Each is then transferred through the tunnel and into the lateral edge of the opposite corpora. Each suture is left untied until after the cuff has been placed, as even the small amount of hour-glassing that occurs after tying the mattress sutures can make cuff placement difficult.

Figure 4

Cuff selection and placement. (A) Due to the inelastic corporal tissue, we select the size of our cuff based on the exact circumference measured. (B) Final appearance of the transcorporal cuff after the previously placed mattress sutures are tied.