Management Nuances for the Incontinent Prostate Cancer Survivor
The artificial urinary sphincter is an implantable device designed to treat incontinence in prostate cancer survivors. The device has existed for 50 years, and in that time, best practices around its use have undergone several paradigm shifts.
In this video, Jay Simhan, MD, FACS, Professor in the Department of Urology and Director of Reconstruction and Prosthetics at Fox Chase Cancer Center, presents a brief set of updates for providers to consider when treating this patient population.
Design of the artificial urinary sphincter and how it works
Perioperative management guidance – avoiding catheters
Cuff size considerations – smaller isn’t always better
Double-cuffing – research opposing this practice
Erosion management and fixing holes in the urethra
Hi, my name is J. Simpson and I'm currently professor of urology at Fox Chase Cancer Center. And I helped lead our reconstructive urology program um both for our patients as well as our training program for fellowship training. The title of this really brief talk today is to go over management of the artificial urinary sphincter. And some of this is nuances for the management or treatment of the incontinent prostate cancer survivor. So you know, some of you who are listening to this might know exactly what I'm talking about. But but not all of you perhaps may have heard of the artificial urinary sphincter and how it works really in men. And it's designed for prostate cancer survivors that might face an adverse outcome following treatment for prostate cancer where they face urinary incontinence. So this is what it is. It's actually an implantable device. It comes with three components. There's a cuff which I think of it like a blood pressure cuff or a tourniquet that goes around the urethra, a regulating balloon as well as a control pump. Now these three items work in the human body by going around the urethra. The pump goes in the scrotum and this balloon mechanism is actually implanted near the bladder and it's easy for me to sort of show this. But really a good video that the company has put out that makes this product helps show how it works in real life. So what happens is these three components are sort of installed surgically and then the patient sort of is asked to, you know when they're ready to avoid they feel the sensation and the urge to go, they manipulate the pump in their scrotum, they squeeze it, the tourniquet or the cuff opens and they're able to urinate. So it dramatically improves the leakage rates or urinary leakage following prostate cancer treatment and automatically. Once the bladder is empty, the tourniquet actually refills and squeezes the urethra again. So you don't need to do anything other than squeeze the pump several times in the beginning and then you're able to pee. So, so here the stuff to know about it has really nothing to do with erectile dysfunction. That's another sometimes adverse event following prostate cancer treatment. We can talk about that. And then, you know, I have a large series as well of penile implant patients and prostate cancer survivors that certainly have benefited from erectile dysfunction treatment. These are very grateful patients, devices have been around for decades, but there are very few surgeons that actually have a practice dedicated to managing this. A lot of the patients can undergo revisions. Certainly some of that based on experience and you really shouldn't put a urinary catheter in any patient that has that type of a device in and and and just stands to reason that why would you put a catheter in someone that might have a cuff around their urethra, you could really damage the cuff. So I'm a big believer that really the most optimal outcome in patients that undergo surgery or under or to have really the technical performance of the operation with peri operative management then yields the most optimal patient outcome. And I might talk some about technical performance. And my hope is that at Temple Health we have some of the benefits of performing the surgeries are complex as well as we can and and those that are technically challenging, We try to get patients through the best we can. But ultimately peri operative management, I think also plays a huge role. So let me sort of talk about some of the things that we think promote the most optimal success surgically peri operatively in these types of patients. So I told you about avoiding a catheter in radiated patients. This is really the best and worst treatment because it's the only treatment really in patients that are radiated but you do face the risk of erosion of the device, which can then require more surgery. And I really use Sista Skopje and the Office or Euro Dynamics, which is advanced bladder testing to help assess artificial sphincter patients. So I'll go through some of the paradigm shifts and where, you know, I've I've tried to sort of help move the needle towards management of these patients and and hopefully it generates thoughts questions and certainly people can reach out if they have any concerns and or questions about management of artificial sphincter patients as it relates to their patient population. So one of the paradigm shifts, you know, as it relates to the artificial sphincter was really, you know, look at the urethra, put a tourniquet around it, put a cuff around it and some urethra were just too small. So you need smaller cuffs. So the company, you know, that makes this really had cuffs that were around the five or six centimeter arranged at first. Then they developed a 4.5 and they developed a force centimeter cuff. And as men with prostate cancer were living to be older and older, their tissues got weaker and weaker and so their urethra has got more narrower and narrower, if that's a word. And ultimately, the company came out with an even smaller cuff, 3.5 centimeter cuff. And and they said in the smallest urethra, when you look in with a camera, this is how the urethra closed. And you know, earlier on, around, you know, 10 years ago, I helped lead a series where we demonstrated that patients with larger sized cuffs really benefited from undergoing a cuff revision to a smaller size cuff. To this smaller 3.5 centimeter cuff. And then with more patients. And with a larger series, we were able to show that the 3.5 centimeter cuff patient actually did okay, except for if they were radiated and the radiated patients just did not do as well. And the lifespan of the device was much poorer and the quality of the patient quality of life was also poorer, you know. One of my colleagues at another institution then led a series where he also demonstrated in a large series of patients that the 3.5 centimeter cuff, the smallest cuff actually also had a few mechanical failures which were significantly more than the other sizes here. So, so you know, we saw the needle for artificial sphincters really change over time. So in the last 5 to 7 years, I would say it became a fad where the 3.5 centimeter cuff was something that a lot of surgeons incorporated and I would say now, given given increased evidence more and more surgeons are somewhat abandoning it. Now, another strategy that had really come up was for these types of patients, Maybe instead of placing one cuff around the urethra, you just placed several, maybe you place two cups two tourniquets around the urethra and that helps prevent any urinary leakage because the resistance to flow through the urethra around two urethral cuffs is just much more and patients then wouldn't leak. And and ultimately this too was something that had been studied quite in depth by another institution, out of johns Hopkins University. And they demonstrated that really placing two cuffs actually adds no benefit whatsoever and that, you know, you really should place one so out in the community. This is something that might be done still today where patients might undergo sort of a more elaborate operation of placing two cuffs around the urethra. It's ultimately not necessary. And really if you size a patient with one cuff alone in the right location, patients just seem to do better. And yet this is another series that demonstrated that the double cuff really didn't do as well. And that patients required more revision surgery somewhat because of it. Now, a large part of my practice also talks about and and manages urinary reconstruction. So this is a type of reconstruction where you put in a prosthetic device um and and manage it. But sometimes, you know, the complications of these devices could be challenging and you know, the artificial sphincter as I talked about, if you leave a fully catheter or you put a fully catheter in that type of a patient, you really risk something called an erosion event. And an erosion event is basically when you see the device cyst aske optically in the urethra. So this is a cyst aske opic view of the urethra and you can actually see at the three o'clock position this device. So when you see that that's of concern. And ideally if you see that you can see the hole in the urethra surgically go in and put some stitches in and fix it. Again, something that, you know, I published on just over the past several years. But in real life, this is not what it looks like. This is a real life patient picture of what that looks like. It's it's really like a bomb went off in there and you really have to try to sort of manage the patient. You know get them better from an acute infection and also do the reconstruction. And so we've been able to do that um successfully in patients to place those tough to place stitches. And we've been happy to take care of erosion events in patients that are our own patients. But also patients that might have this done elsewhere in the community that then present with an erosion that we're happy to take care of. So I want to summarize again this brief talk with some take home points in general. I'll say the artificial urinary sphincter has nothing to do with the D patients can go management of their incontinence and patients can undergo management of their erectile dysfunction. These are very grateful patients. The device has been around for 50 years but the average urologist has less than one in their career. Um So so it's just not done often in the in the community and and we're very fortunate to have the experience to be able to manage many many patients with these problems. Um Many patients can undergo revisions for some of the stuff I talked about the sort of additive issues with radiation but also because of really just the nuances of tissues getting weaker over time that require more more revision of the product. And finally we really recommend strongly that patients should not undergo a catheter that have an artificial sphincter. And you really should be discussing that. Hopefully, you know, we're happy to be a resource to discuss that with you or with really the implanting surgeon. If it's not someone on our team. Now, some of the details I would say about the artificial sphincter or to avoid the double cuffs, maybe avoid the 3.5 centimeter cuff if you're not certain, go with a bigger size and fix the holes in the reef for during erosion management. Thanks again for tuning in. And I hope this was of help as you face some of these challenging patients in your practice.