title: Transcorporal artificial urinary sphincter cuff placement in cases requiring revision for erosion and urethral atrophy.
abstract: OBJECTIVE
  A distal cuff location is often required in patients undergoing artificial urinary sphincter reimplantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small that a 4 cm. cuff is too large. We present a novel technique for distal cuff placement using transcorporal dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk.
  
  
  METHODS
  We reviewed the charts of 31 men who underwent this technique and contacted 26 by telephone. The indications for distal transcorporal cuff placement varied. In 7 men with inadequate urethral coaptation with a 4 cm. proximal cuff at initial implantation a primary transcorporal tandem cuff was implanted distal. In 8 men persistent or recurrent incontinence despite a 4 cm. proximal cuff led to secondary distal reimplantation. Previous artificial urinary sphincter erosion and/or infection in 10 cases, previous urethral surgery at the optimal cuff site in 5 and radiation changes at the optimal cuff site in 1 led to selection of the more distal site and technique. Of the transcorporally placed cuffs 18 were 4 cm. and 13 were 4.5 cm. Preoperatively 5.2 pads were used daily. Of the 31 patients 27 were impotent preoperatively, 1 had normal erections, 1 had partial erections with the MUSE drug delivery system (Vivus, Inc., Menlo Park, California) and 2 had a previously placed penile prosthesis.
  
  
  RESULTS
  At a mean followup of 17 months 26 of the 31 patients (84%) had occasional or no stress incontinence requiring 0 to 1 pad daily, 2 with pure urge incontinence used 1 to 2 pads daily and 3 had mixed incontinence requiring 0 to 3 pads daily. Of the 26 men surveyed 25 were very satisfied with the postoperative level of incontinence. Postoperatively erectile function deteriorated in 1 patient and was unchanged in the remainder. There was no erosion or infection of the transcorporally placed cuffs, although 3 were replaced for malfunction.
  
  
  CONCLUSIONS
  This technique offers significant advantages in cases of revision. The technique protects the urethra from intraoperative dissection injury and decreases the risk of erosion because the urethra is buttressed at its vulnerable location. In addition, bulk is added to the urethra, allowing for better cuff sizing, which is usually a problem at this location where the urethra is small, thereby, improving continence in revised cases. Our success has recently led us to abandon tandem cuff placement altogether. There is a potential for deteriorating erectile function in potent men who undergo implantation in this fashion.
authors.affiliation: Division of Urology, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Guralnick
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Miller
authors.forename: Khai Lee
authors.initials: KL
authors.lastname: Toh
authors.forename: George D
authors.initials: GD
authors.lastname: Webster
mesh_terms: D001284:Atrophy; D004210:Dissection / Q000379:methods; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D011468:Prostatectomy; D011474:Prosthesis Design; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D014521:Urethra / Q000473:pathology* / Q000601:surgery; D014549:Urinary Incontinence / Q000209:etiology / Q000601:surgery; D016741:Urinary Sphincter, Artificial