ARTIFICIAL BLADDER SPHINCTERS
1
86 ARTIFICIAL BLADDER SPHINCTERS IT is some ten years since the introduction of artificial bladder sphincters,’ and there has been much progress. Incontinence of urine is usually due to failure of one or more of the three main aspects of bladder function-storage, emptying, and control. Avoidance of storage failure (which when incomplete is known as stress incontinence) requires but a centimetre or so of healthy urethra within the abdominal cavity and a firm pelvic floor so that abdominal-pressure increases are transmitted to the abdominal urethra as well as the bladder. This is the context in which an artificial sphincter may be useful. In neither sex is the external urethral sphincter important and the artificial sphincter, unlike the artificial heart valve, is not designed to replace a diseased organ. Advances in diagnosis and in conventional treatment have greatly improved the outlook in storage failure, but when standard operative treatment does not succeed the resultant scarring and infection will reduce the chance of a successful implant. For an inflatable prosthesis to be successful, the patient must be able to empty the bladder completely, which in neuropathic cases may require abdominal straining or manual bladder compression. With lower motor neuropathy and a flaccid pelvic floor there may have been stress incontinence from the outset, or it may have begun after operations to eliminate residual urine. In upper motor neuron lesions, stress incontinence only follows extensive bladder-neck resection combined with internal membranous urethrotomy. An implant will succeed here only if detrusor hyperreflexia can be controlled by anticholinergic therapy or sacral root section. A survey of nine recent reports (all from the USA) on the use of artificial bladder sphincters provides data on over 300 patients.2-10 The ratio of adults to children and also of males to females is about 10 to 1. Vesico-urethral neuropathy and radical prostatectomy for carcinoma each accounts for about a third of the cases while transurethral and abdominal operations for benign prostatic obstruction were responsible in about a fifth. Only 6 women with "simple" stress incontinence are included. The original Scott-Bradley-Timm artificial sphincter (American Medical Systems, AS721) has been simplified and improved repeatedly. In the latest versions (AS791 and 792, for application to the urethral bulb and bladder-neck, respectively) a small stainless steel control assembly is connected to the cuff, to a pressure-regulating reservoir, and to a single scrotal or labial bulb. Pressure on the bulb empties the cuff which is refilled automatically after a delay of a few minutes to allow voiding. Abdominal pressure changes are transmitted from the reservoir to the cuff but the cuff empties in response to unphysiological intravesical pressures. Early on, there was a high incidence of technical failure (including leaks, kinks, and valve faults) and erosion of the bladder-neck or urethra which meant that most patients 1. Scott FB, Bradley WE, Timm GW Treatment of urinary tract incontinence by implantable prosthetic sphincter Urology 1973, 1: 252. 2. Giesy JD, Barry JM, Fuchs EF, Griffith LD. Initial experience with the Rosen incontinence device J Urol 1981; 125: 794-95 3. Montague DK. The Scott-Bradley-Timm artificial urinary sphincters J Urol 1981; 125: 796-99. 4. Bruskewitz R, Raz S, Kaufman JJ Treatment of urinary incontinence with the artificial sphincter J Urol 1981, 126: 469-72. 5. Furlow WL. Implantation of a new semiautomatic artificial genitourinary sphincter: Experience with primary activation and deactivation in 47 patients. J Urol 1981; 126: 741-44. 6. Hanna MK. Artificial urinary sphincter for incontinent children Urology 1981, 18: 370-73. 7. Malloy TR, Wein AJ. Carpiniello VL. Surgical results with artificial urinary sphincter. Urology 1982; 21: 602-05 had to have one or more reoperations. The Rosen modification2 is easy to insert and operate and attractively priced, but still cannot be recommended. The success rate of the AS791 and 792 is now 60 or 70% over periods ofup to five years. The cuff pressures (50-70 cm of water) and delayed activation of the implants (especially in patients with recent erosions or operations at the cuff site) are universally acknowledged to be beneficial. A surprisingly high success rate has been achieved in neuropathic cases even in children6,8 some of whom had been left incontinent following "undiversion".’° (In one boy prostatic obstruction developed within the cuff at puberty. 8) Artificial sphincters will be used increasingly in the management of urinary incontinence despite the high cost of the implants (said to be 2000 in one European country), and surely few will disagree with the originator, F. Brantley Scott" when he says "Incontinence is a problem sufficiently complicated that most patients should be treated by a sub- specialist in Urology". Meanwhile, there is scope for prevention. The news from the UK is both good and bad in this respect. The bad news is that far too many British surgeons attempt transurethral prostatic resection without training; the good news is that radical surgery has never been seen to have any place in the management of carcinoma of the prostate. TRAINING FOR INTENSIVE CARE i i is over 20 years since tne tirsi intensive-care units were set up in the United Kingdom. They were a natural development from the respiratory units of the 1950s, and a necessary development in the increasing complexity of medicine and surgery. Now almost all district general hospitals as well as teaching hospitals have one. The clinical picture of system failure tends to be much the same whatever the underlying disease. Successful management demands a detailed knowledge of these clinical states as well as familiarity with the equipment and techniques used in intensive care. The subject is given prominence in the final FFA RCS examination, and trainee physicians and surgeons can expect to be asked about some aspects of it in their postgraduate examinations, but training in intensive care has not been formalised in the United Kingdom. A study by Hillman, Hinds, and Willitts’ has highlighted this issue. A questionnaire was sent to senior registrars in general medicine and anaesthesia, inquiring into the amount of training they received in intensive care. Although only 33% of anaesthetists and 21% of physicians replied some important points emerge. Over half the trainees had had less than six months’ training in intensive care. 17% of physicians had had none at all. In some units there were no regular rounds. Overall there was a dismal lack of formal teaching. Almost half of the anaesthetists, but a smaller proportion of physicians, thought that their training in intensive care was adequate. 76% of all respondents believed that intensive-care units should be run by specialists but only a few regarded a 8. Gonzalex R, Sheldon CA. Artificial sphincters in children with neurogenic bladders: Long-term results J Urol 1982; 128: 1270-71. 9. Barrett DM, Furlow WL. Radical prostatectomy incontinence and the AS791 artificial urinary sphincter. J Urol 1983; 129: 528-30. 10. Light JK, Flores FN, Scott FB. Use of the AS792 artificial sphincter following urinary undiversion. J Urol 1983; 129: 548-51. 11. Scott F. Guest editorial. J Urol 1981; 125: 799. I Hillman K, Hinds CJ, Williatts SM. Training in intensive care. Anaesthesia 1983, 38: 540-45. 2. Gilston A. Intensive care in England and Wales. Anaesthesia 1981; 36: 188-93.
Transcript of ARTIFICIAL BLADDER SPHINCTERS
86
ARTIFICIAL BLADDER SPHINCTERS
IT is some ten years since the introduction of artificialbladder sphincters,’ and there has been much progress.Incontinence of urine is usually due to failure of one or moreof the three main aspects of bladder function-storage,emptying, and control.Avoidance of storage failure (which when incomplete is
known as stress incontinence) requires but a centimetre or soof healthy urethra within the abdominal cavity and a firmpelvic floor so that abdominal-pressure increases aretransmitted to the abdominal urethra as well as the bladder.This is the context in which an artificial sphincter may beuseful. In neither sex is the external urethral sphincterimportant and the artificial sphincter, unlike the artificialheart valve, is not designed to replace a diseased organ.Advances in diagnosis and in conventional treatment have
greatly improved the outlook in storage failure, but whenstandard operative treatment does not succeed the resultantscarring and infection will reduce the chance of a successfulimplant. For an inflatable prosthesis to be successful, thepatient must be able to empty the bladder completely, whichin neuropathic cases may require abdominal straining ormanual bladder compression. With lower motor neuropathyand a flaccid pelvic floor there may have been stress
incontinence from the outset, or it may have begun afteroperations to eliminate residual urine. In upper motorneuron lesions, stress incontinence only follows extensivebladder-neck resection combined with internal membranous
urethrotomy. An implant will succeed here only if detrusorhyperreflexia can be controlled by anticholinergic therapy orsacral root section.A survey of nine recent reports (all from the USA) on the
use of artificial bladder sphincters provides data on over 300patients.2-10 The ratio of adults to children and also of malesto females is about 10 to 1. Vesico-urethral neuropathy andradical prostatectomy for carcinoma each accounts for about athird of the cases while transurethral and abdominal
operations for benign prostatic obstruction were responsiblein about a fifth. Only 6 women with "simple" stress
incontinence are included. The original Scott-Bradley-Timmartificial sphincter (American Medical Systems, AS721) hasbeen simplified and improved repeatedly. In the latestversions (AS791 and 792, for application to the urethral bulband bladder-neck, respectively) a small stainless steel controlassembly is connected to the cuff, to a pressure-regulatingreservoir, and to a single scrotal or labial bulb. Pressure on thebulb empties the cuff which is refilled automatically after adelay of a few minutes to allow voiding. Abdominal pressurechanges are transmitted from the reservoir to the cuff but thecuff empties in response to unphysiological intravesical
pressures. Early on, there was a high incidence of technicalfailure (including leaks, kinks, and valve faults) and erosion ofthe bladder-neck or urethra which meant that most patients
1. Scott FB, Bradley WE, Timm GW Treatment of urinary tract incontinence byimplantable prosthetic sphincter Urology 1973, 1: 252.
2. Giesy JD, Barry JM, Fuchs EF, Griffith LD. Initial experience with the Rosenincontinence device J Urol 1981; 125: 794-95
3. Montague DK. The Scott-Bradley-Timm artificial urinary sphincters J Urol 1981;125: 796-99.
4. Bruskewitz R, Raz S, Kaufman JJ Treatment of urinary incontinence with the artificialsphincter J Urol 1981, 126: 469-72.
5. Furlow WL. Implantation of a new semiautomatic artificial genitourinary sphincter:Experience with primary activation and deactivation in 47 patients. J Urol 1981;126: 741-44.
6. Hanna MK. Artificial urinary sphincter for incontinent children Urology 1981, 18:370-73.
7. Malloy TR, Wein AJ. Carpiniello VL. Surgical results with artificial urinary sphincter.Urology 1982; 21: 602-05
had to have one or more reoperations. The Rosenmodification2 is easy to insert and operate and attractivelypriced, but still cannot be recommended. The success rate ofthe AS791 and 792 is now 60 or 70% over periods ofup to fiveyears. The cuff pressures (50-70 cm of water) and delayedactivation of the implants (especially in patients with recenterosions or operations at the cuff site) are universallyacknowledged to be beneficial. A surprisingly high successrate has been achieved in neuropathic cases even inchildren6,8 some of whom had been left incontinent following"undiversion".’° (In one boy prostatic obstruction developedwithin the cuff at puberty. 8)
Artificial sphincters will be used increasingly in the
management of urinary incontinence despite the high cost ofthe implants (said to be 2000 in one European country), andsurely few will disagree with the originator, F. BrantleyScott" when he says "Incontinence is a problem sufficientlycomplicated that most patients should be treated by a sub-specialist in Urology". Meanwhile, there is scope for
prevention. The news from the UK is both good and bad inthis respect. The bad news is that far too many British
surgeons attempt transurethral prostatic resection withouttraining; the good news is that radical surgery has never beenseen to have any place in the management of carcinoma of theprostate.
TRAINING FOR INTENSIVE CARE
i i is over 20 years since tne tirsi intensive-care units wereset up in the United Kingdom. They were a natural
development from the respiratory units of the 1950s, and anecessary development in the increasing complexity ofmedicine and surgery. Now almost all district generalhospitals as well as teaching hospitals have one. The clinicalpicture of system failure tends to be much the same whateverthe underlying disease. Successful management demands adetailed knowledge of these clinical states as well as
familiarity with the equipment and techniques used in
intensive care. The subject is given prominence in the finalFFA RCS examination, and trainee physicians and surgeonscan expect to be asked about some aspects of it in their
postgraduate examinations, but training in intensive care hasnot been formalised in the United Kingdom.A study by Hillman, Hinds, and Willitts’ has highlighted
this issue. A questionnaire was sent to senior registrars ingeneral medicine and anaesthesia, inquiring into the amountof training they received in intensive care. Although only33% of anaesthetists and 21% of physicians replied someimportant points emerge. Over half the trainees had had lessthan six months’ training in intensive care. 17% of physicianshad had none at all. In some units there were no regularrounds. Overall there was a dismal lack of formal teaching.Almost half of the anaesthetists, but a smaller proportion ofphysicians, thought that their training in intensive care wasadequate. 76% of all respondents believed that intensive-careunits should be run by specialists but only a few regarded a
8. Gonzalex R, Sheldon CA. Artificial sphincters in children with neurogenic bladders:Long-term results J Urol 1982; 128: 1270-71.
9. Barrett DM, Furlow WL. Radical prostatectomy incontinence and the AS791 artificial
urinary sphincter. J Urol 1983; 129: 528-30.10. Light JK, Flores FN, Scott FB. Use of the AS792 artificial sphincter following urinary
undiversion. J Urol 1983; 129: 548-51.11. Scott F. Guest editorial. J Urol 1981; 125: 799.
I Hillman K, Hinds CJ, Williatts SM. Training in intensive care. Anaesthesia 1983, 38:540-45.
2. Gilston A. Intensive care in England and Wales. Anaesthesia 1981; 36: 188-93.
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