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Bioengineering in Urology > Artificial Urinary Sphincters, Stents, Slings & Meshes > Flashcards

Artificial Urinary Sphincters, Stents, Slings & Meshes Flashcards

1
Q

Define genuine stress incontinence

A

Loss of urine which occurs when bladder pressure exceeds urethral pressure in the absence of detrusor activity

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2
Q

Causes of genuine stress incontinence

A
  • raised abdominal pressure (coughing)
  • incompetent bladder neck or hypermobile urethra
  • intrinsic sphincter deficiency
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3
Q

RF of genuine stress incontinence in males

A
  • post prostatectomy
  • > 1% post TURP
  • 5% post retropubic prostatectomy for BPH
  • 10% post prostatectomy for prostate cancer
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4
Q

RF for genuine stress incontinence in females

A
  • multiparity (vaginal delivery)
  • obesity
  • pelvic surgery
  • oestrogen withdrawal
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5
Q

RF for genuine stress incontinence in both males and females

A

LMN nerve injury = sphincter denervation

  • spinal cord injury below T12
  • nerve damage following spinal surgery
  • sacral nerve damage following tumour removal
  • spina bifida
  • MS
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6
Q

Medical management options for genuine stress incontinence

A
  • pelvic floor exercises
  • electrical stimulation
  • biofeedback of pelvic floor contraction
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7
Q

Surgical management options for genuine stress incontinence

A
  • slings/pubovaginal/autologous/TVT
  • injectables (collagen, macroplastique)
  • open procedures (vagino-obturator, burch colposuspension)
  • artificial urinary sphincter
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8
Q

What does an artificial urinary stent comprise of?

A
  • pressure regulating balloon
  • urethral cuff
  • pump
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9
Q

What are artificial urinary sphincters made from?

A
  • silicone rubber
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10
Q

What are some examples of artificial urinary sphincters?

A
  • AMS AS-800

- Flowsecure AUS

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11
Q

AMS AS-800 Design Features

A
  • individual parts filled and joined in theatre (modular assembly)
  • different balloon sizes for each pressure regulation
  • cuff formed as a flat piece
  • different size cuffs for each patient
  • deactivation button on pump
    (urethral cuff + pressure regulating balloon + pump)
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12
Q

Flowsecure AUS Design Features

A
  • one piece = no assembly
  • stress relief facility for conditional occlusion
  • circular cuff to reduce creasing
  • one size urethra cuff
  • adjustable pressure regulation through self sealing port in pump
    (urethral cuff + pressure reg balloon + stress relief reservoir + pump & self sealing port)
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13
Q

Function of AUS devices

A
  • deflation
  • re-inflation
  • conditional occlusion
    (see lecture diagram)
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14
Q

Contra-indications for AUS devices

A
  • unmanaged detrusor instability
  • previous radiotherapy of the lower urinary tract
  • problems affecting manual dexterity or motivation (may prevent patient operating device)
  • acute UTI (may get post-op complications)
  • open surgical procedure risks regarding medical history
  • known sensitivity to silicone rubber
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15
Q

How to insert a Flowsecure AUS?

A
  • excise urethra through perineal
  • make an abdominal incision and pass trocar through perineal incision
  • device is prefilled on sterile field and prepared for implantation
  • clamp tube just below regulating balloon with protected forceps, gently squeeze fluid out of cuff with fingers and clamp just below stress relief balloon so fluid cannot return
  • remove stylet from trocar and pass the deflated cuff through it to the perineal site
  • remove trocar downwards over cuff at perineal site leaving the pump and balloon protruding from abdominal incision above
  • place cuff around urethra loop until it is a comfortable fit but not too tight
  • apply glue and single stitches at top, middle and bottom of belt to ensure a secure fix
  • place balloons in abdominal pouches
  • place pump in scrotum
  • at a later date, device is pressurised by injecting sterile saline through self-sealing port in the base of the control pump
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16
Q

Differences between Flowsecure and AMS-AS 800?

A
  • Flowsecure one piece assembly so quicker + simpler implantation vs. AMS tedious assembly which may introduce infection
  • pressure can be adjusted without need for surgical revision in Flowsecure vs. AMS pressure only increased by surgical revision of pressure balloon
  • Flowsecure stress relief facility provides conditional occlusion so device may be able to run at a lower pressure vs. AMS pressure must be set to high to maintain continence even during stress perods
17
Q

How is sterile saline injected?

A
  • scrotal area prepared under aseptic technique
  • 25G short needle filled with sterile saline
  • self sealing port in base of pump located
  • pump sterile saline into pump
  • remove needle and redistribute fluid by pumping device
18
Q

How to assess continence?

A
  • 7 day voiding and leakage diary
  • ICIQ (Quality of Life Questionnaire)
  • Measurement of intake/voiding/leakage (pad weighing)
  • continence index
19
Q

How to calculate continence index?

A

= 100 x Voided volume/ (Leaked volume + voided volume)

20
Q

Potential Complications with AUS

A
  • recurrent incontinence
  • infection
  • mechanical failure
21
Q

How may you get recurrent incontinence? How should it be managed?

A
  • pressure may not be high enough
  • may need to carry out additional pressurisation (flowsecure)
  • may need to re-operate and replace balloon for higher pressure one
  • urethral atrophy
  • infection
  • mechanical failure
22
Q

Why may you get infection? How should it be managed?

A
  • acquired at surgery

- may need to remove device and replace

23
Q

How to manage mechanical failure?

A
  • if spontaneous = device removal and replacement
  • if flowsecure = whole device replaced
  • if AS-800 = modular components replaced
24
Q

How to image AUS devices?

A 
AS-800 = fill with radio-opaque solution then x-ray image
Flowsecure = MRI or US
25
Q

Difference in pressure-volume characteristics of Flow secure vs. AMS AS 800

A

Flow secure = at low volumes pressure ranges 50-70
AMS AS 800 = at higher volumes pressure reaches 50-80
Flowsecure can run at lower pressures but AMS needed to run at higher pressures to maintain continence

26
Q

Clinical Trial of Flowsecure

A
  • male patients with urodynamically proven stress incontinence = previous Tx with conservative methods/augmentation with injection not excluded/ unctonrolled detrusor actviity not excluded
  • pre-op, pressurisation, 3/6 and 12 month visits (urine analysis and culture, cystometrogram and flow rate, stress tests and 7 day voiding and leakage diary)
  • additional pressurisation procedures as neccessary based on patient symtpoms

Bioengineering in Urology (8 decks)

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