For referring physicians
Incontinence after prostate treatment and reconstruction: how I sequence the sphincter
Stress incontinence in the man who has had a prostatectomy, radiation, or a posterior urethral or bladder neck reconstruction, and the woman whose sphincter has failed. Most of what I do here is decide when, not whether.
Never at the same sitting
A sphincter never goes in at the same operation as a urethral or bladder neck reconstruction. The repair has to work first, and a cystoscopy, not the calendar, says when it has. Three months is the floor everywhere, because the wound has to heal and the sutures have to dissolve. Six months is the default in a radiated field. I scope the radiated patient at three months to see whether he can be brought forward, so six is where he lands if the early look does not support moving, not a waiting period to be served.
The gate is patent, stable and healed, and healed means looking at the mucosa and seeing that it looks right. A bad cystoscopy is a lumen that will not pass, mucosa that looks unhealthy, or a repair that has not healed at all, with calcification or necrosis. The scope that crosses but finds stones is the ambiguous case. A bad cystoscopy does not automatically mean reoperation; it can mean waiting and scoping again, and the patient's symptoms decide which. The heroic single sitting, reconstruction plus sphincter sold as the way to avoid a bag, is the failure mode this rule exists to prevent.
The conversation before the repair
Before I operate on a continent man's posterior urethra, he understands that he may not stay continent and that incontinence has treatments. In our 105 robotic posterior urethroplasties, 29 percent of men went on to a sphincter. After excision and anastomosis for a radiated bulbomembranous stenosis, one in five did. Those are the numbers I give, and the sphincter is part of the plan from the first visit rather than a surprise at the second.
Robotic bladder neck reconstruction changed that arithmetic. Pooled across the published series, de novo incontinence after a robotic repair was 17 percent, against the high rates that follow a perineal reconstruction, and a man who does need a sphincter afterward comes to it with an undissected perineum.
The radiated and reoperative urethra
Radiation shortens the life of every sphincter. In the TURNS redo series the first device lasted a median of 26 months in radiated men against 36 in the others, and each replacement lasted less. A second sphincter in a man with no other risk factor does about as well as a first one; radiation plus a prior urethroplasty brings five-year revision-free survival below half. Prolonged catheterization after placement, radiation and revision surgery were the independent predictors of cuff erosion in our earlier series, which is why a catheter through a cuff is a decision and not a default.
When a cuff has eroded and left a stricture, the stricture is repaired first, usually by excision and anastomosis, and a replacement sphincter follows at about six months. That replacement erodes more often than a first device, and longer strictures erode more, which is the counseling for the man who has already lost one. A transcorporal cuff protects a thin urethra at the price of more urinary retention. A defunctionalized reservoir from an earlier device can be drained and left in place without raising the infection rate.
Women
A woman whose sphincter has failed can have an artificial sphincter placed robotically, with the cuff at the bladder neck. The SP video shows the operation.
When the outlet is closed instead
Some outlets cannot be made continent and cannot be repaired. Closing the bladder neck and draining the bladder through a suprapubic tube or a catheterizable channel is an operation with its own consent, and it belongs to the reconstruct-or-divert decision on the urinary diversion page.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Artificial urinary sphincter
Male sphincter placement and revision
Videos are being edited for the library.
The reconstruction the sphincter waits for
Papers
- Outcomes and risk factors of revision and replacement artificial urinary sphincter implantation in radiated and nonradiated cases. J Urol. 2020. PubMed 31951498
- Outcomes of urethroplasty to treat urethral strictures arising from artificial urinary sphincter erosions and rates of subsequent device replacement. Urology. 2017. PubMed 28624554
- Is prolonged catheterization a risk factor for artificial urinary sphincter cuff erosion?. Urology. 2013. PubMed 24074987
- Transcorporal artificial urinary sphincter cuff placement is associated with a higher risk of postoperative urinary retention. Can J Urol. 2013. PubMed 23783046
- Decreasing need for artificial urinary sphincter revision surgery by precise cuff sizing in men with spongiosal atrophy. J Urol. 2014. PubMed 24746880
- Safety of the "drain and retain" option for defunctionalized urologic prosthetic balloons and reservoirs during artificial urinary sphincter and inflatable penile prosthesis revision surgery: 5-year experience. Urology. 2013. PubMed 24125688
- Summarizing the evidence for robotic-assisted bladder neck reconstruction: systematic review of patency and incontinence outcomes. Asian J Urol. 2023. PubMed 39139537
- Patency and incontinence rates after robotic bladder neck reconstruction for vesicourethral anastomotic stenosis and recalcitrant bladder neck contractures: the TURNS experience. Urology. 2018. PubMed 29777787
- Robotic-assisted posterior urethroplasty: outcomes from 105 men in a single-center experience. Urology. 2023. PubMed 37543119
- Urethral stricture management in male candidates to artificial urinary sphincter: is the best always the enemy of the good?. Prog Urol. 2020. PubMed 32376212
- Prevalence of post-micturition incontinence before and after anterior urethroplasty. J Urol. 2018. PubMed 29654804