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I am Dr. Todd Brandt. I am a urologist. 

These are words I couldn't have imagined myself saying as I was growing up thinking about medicine as a career. 

And I have been asked many, many times why I went into urology as a medical specialty. In this podcast I attempt to explain how I got here. Why did I choose urology as a specialty? Why do I like it? Why, if you are someone with a urinary tract, should you care? Get it? Why Urology.

This podcast is a personal experiment in medical audio content. I make the obvious disclaimer that this is not medical advice. You should be going to your own physician for that.

These episodes are meant to educate, entertain, inspire or inform you in some way with urology as the launching point for each episode. Each episode is varied in format and length as I have experimented with content. 

Listen, follow, share, rate, review, repeat...you know what to do.

If you have kidney stones, or prostate cancer, or another urologic health concern this podcast may help you.

If you have a loved one with any urologic health concern this podcast may help you. 

If you are someone who has asked, "How does my bladder do it's thing?", this podcast may help you.

If you make urine, or even if you don't, this podcast may help you.

Thank you for listening to this podcast. I do appreciated any feedback I get so please reach out to me at the link provided on this website. 

Be well,

Dr. Todd Brandt

Aug 8, 2021

Recently I have been working on putting some videos together using my ten questions model for the artificial urinary sphincter and the male sling procedures used to treat post prostatectomy incontinence.

We last time talked about the artificial urinary sphincter was back in episode 15.

 

These are simple videos done vidscrip style, just me in front of a camera, and you find links to the videos at

https://www.vidscrip.com/toddbrandt

and more specifically at the link

https://app.vidscrip.com/vidscrip/5726cbc9a254a5897c3cbdb9

You can find my episode on the ten questions at episode 97.

Men who have leakage after prostate removal for prostate cancer most often have stress incontinence. Men will leak when coughing, sneezing, lifting or any activity that increase intraabdominal pressure. The urinary sphincter muscle and the urethral mucosa my not have sufficient coaptation after surgery to prevent leakage with those maneuvers.

Men may have different amounts of leakage depending on the level of success from the surgery, anywhere from full control without any leakage (the most common result) to severe heavy leakage. Candidates for an artificial urinary sphincter are generally men with moderate to severe urinary leakage using multiple pads or diapers every day.

There are 3 components to an artificial urinary sphincter. First, there is a balloon cuff that is placed around the urethra which does the work of pinching the urethra to prevent the leakage Second, there is a pump placed in the scrotum which can be manually squeezed to open the cuff to allow a man to urinate. The last component is a pressure regulating balloon that is placed in the abdomen underneath the stomach muscles usually right next to the bladder that pressurizes the cuff to squeeze on the urethra.  

The cuff is always closed because there is pressure in the system. Upon squeezing the pump, fluid is shifted from the cuff to the pressure regulating balloon. This movement of fluid allows the cuff to open resulting in opening of the urethra allowing a man to urinate. The cuff spontaneously closes as fluid returns from the pressure regulating balloon to the cuff.

You can find a video demonstrating the artificial urinary sphincter and how it works at fixincontinence.com and on my vidscrip site. 

Here are the answers to the ten questions about artificial urinary sphincter.

 

What is the diagnosis needed to consider an artificial urinary sphincter?

An artificial urinary sphincter is placed for patients with heavy stress incontinence from an incompetent urinary sphincter. In this episode’s specific use case we are using it to correct leakage for the small percentage of men with severe leakage after prostate removal for treatment of prostate cancer.

Can we briefly describe the procedure?

The way that I place the device is to make two small incisions. The AUS is placed through an incision in the perineum (space between the anus and the scrotum) as well as a small incision in the lower abdomen. The three components are placed through the two incisions.  The cuff is placed through the perineal incision and the pressure regulating balloon and the pump are placed through the incision made in the lower abdomen.

Alternatively, the device can be placed through a single incision in the scrotum. Some surgeons prefer that approach. I find it difficult to place the sphincter cuff in a position that I prefer from that single incision.

The surgery can be performed with either a general or spinal anesthesia and patients typicallyspend one night in the hospital. 

What is the goal of this procedure?

The goal of the procedure is full continence and full control of the urine.  The artificial sphincter is not a guarantee of complete control. It is probably about 85% successful at getting men to a level of dryness that is minimal pad usage. The reason it is not more successful is due to the limit of how tightly we can squeeze on the urethra, how much pressure it will tolerate before the urethra begins to shows signs of damage.

What are the drawback and risks?

As with any surgery there are risks bleeding, anesthesia risk and of course the discomfort associated with surgery. But the risks the surgeon worries the most about are risks of infection and urethral injury during the procedure. Long term risks include urethral thinning and erosion,  mechanical breakdown of the device, a failure to relieve the amount of leakage.     

What are alternatives to the artificial urinary sphincter?

Alternatives to the sphincter are continuing the use of the diapers or pads, using an external compression device on the penis such as a Cunningham clamp, biofeedback, and external catheterization such as a condom catheter. Male urethral slings or periurethral balloons can be placed for patients with less incontinence, usually up to only a couple of pads a day, who also have some ability to start and stop the urine stream and some overall control.

How common is this procedure?

The artificial urinary sphincter is a relatively common procedure. Althoughh most men who have had a prostatectomy don’t have leakage severe enough to require a sphincter, there are enough prostatectomies being done annually that a number of patients unfortunately need this procedure.

When should I have an artificial urinary sphincter placed?

The timing of placing a sphincter is usually at least one year from the time of the prostatectomy. It takes time after a prostate is removed for men to regain urinary control. Most men will have good urinary control within the first 3 months after surgery, but some men take much longer. 

Men who are considering an artificial urinary sphincter have already tried Kegel exercises, biofeedback and possibly medication to control the leakage and are not finding any success. Many men choose to wear external compression devices and the urinary pads longer than they need to before making the step for surgery. Choosing when to do this surgery is such a personal decision and the risks are high enough that it’s best to let men choose when the time is right for them. 

Is there special preparation for this procedure?

            There is little preparation needed for this procedure. The usual advice for stopping blood thinning medication, getting preoperative clearance for anesthesia, not eating or drinking prior to the surgery, getting to the hospital on time all exist as for any other procedure.

Patients can help preparing their skin before surgery to help limit infections by washing with antibacterial soap or Hibiclens for a week prior to surgery

Before the day of surgery make sure you have a driver and know the route the hospital, how you will get home the day after surgery (you stay overnight), and who will take care of you when you do get home.

Can you tell me about recovery from this procedure?

Although some doctors send patients home the same day of surgery if I do the surgery you will stay the night in the hospital. Pain is controlled, you will eat a normal diet and begin to walk around on the same day as your surgery.

We leave a catheter in overnight and remove the catheter the next day. The sphincter is left deactivated for the first six weeks after surgery to allow the urethra to heal. That means that you will continue to leak after surgery until the sphincter is activated. I typically activate the sphincter for men six weeks after surgery.       

You will go home on antibiotics. Take the complete course of antibiotics prescribed unless you have a reaction to the medicine. You will also have a prescription for pain medication if you feel you need something stronger than over the counter medications. Many men don’t need the prescription for the pain medication and choose not to take it.

Plan to do only light duty for a couple of weeks after surgery. I usually will have an appt with patients two weeks after the operation to check for adequate healing. That is typically when we negotiate when a man can go back to heavier physical activity.

What about insurance coverage for the procedure?

There is usually good insurance coverage for this procedure. There is a prior authorization process to make sure the procedure is covered handled in my practice by our business office. It’s important obviously to know that you have coverage for this procedure before you get to the hospital on the day of surgery. I have had to cancel procedures for patients or move them from one hospital to the next at the last minute because of a breakdown in this process, and that is not at all fun.  If you are a man considering this procedure, I can tell you that you don’t want to have to sort through the billing issues after the procedure.

That finishes the ten questions about the artificial urinary sphincter. We have been discussing this in the context of men who have had their prostates removed for prostate cancer. For those men, as well as for patients with other forms of urethral sphincter injury or neurologic dysfunction this procedure can make a huge difference in a person’s quality of life.

Find out more about the artificial urinary sphincter at fixincontinence.com or at bostonscientific.com. Find me at whyurologypodcast.com and connect with me there

Thanks for listening.