**3. Comment and conclusion**

In the last years, the urological community has been developing new procedures to treat postprostatic surgery urinary incontinence. Despite their long history of use, collagen injections are associated with low cure rates. Moreover, collagen is gradually reabsorbed by the organism, leading to additional applications of the product, along with no significant increase in long-term cure (Cespedes.1999; Kuznetsov et al. 2000).

The male sling appeared as another alternative treatment for these patients, but seems to be effective only in mild and moderate cases of postprostate surgery urinary incontinence (Castle et al. 2005; Montague et al. 2001).

Although the artificial urinary sphincter is considered as the standard treatment for moderate and severe cases of postprostate surgery urinary incontinence, it is a high-cost device. In the present study, the authors present results of a surgical alternative for the treatment of postprostate surgery urinary incontinence. For this, we used the periurethral constrictor, a two-part device with a constrictor cuff positioned around the bulbar urethra and hydraulically activated through a self-sealing valve with a tube. Previous studies had already presented the device as a safe and effective alternative for the treatment of neurogenic urinary incontinence (Lima SVC, et al. 2000; Vilar FO, et al. 2004).

This is particularly true if we consider that the erosion and infection cases were probably caused by bulbar urethral injuries that occurred during its dissection and cuff positioning in an early phase of the study during the learning curve of the technique. Along the series, there were no new cases of erosion and infection.

Our experience indicates that the periurethral constrictor is less susceptible to mechanical problems or improper functioning, which agrees with the studies of neurogenic patients. The eventual problems were easily managed by simple surgical reviews with local anesthesia in the case of the exchange of leaking valves, or ambulatory reviews to adjust the

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 277

Lima SV et al. Periurethral Constrictor in the Treatment of Neurogenic Urinary Incontinence: the Test of Time. *Brazilian Journal of Urology*, v. 26, p. 415-7, 2000. Lima SVC, Vilar FO, Araújo LAP. Periurethral constrictor in the treatment of neurogenic

Litwiller SE, Kim KB, Fone PD, DeVere White RW, Stone AR.Post-Prostatectomy

Rajpurkar AD, Onur R, Singla A. Patient satisfaction and clinical efficacy of the new perineal

Rocha FT. Avaliação dos resultados do tratamento da incontinência urinária pós-

*obtenção do Título de Professor Livre-docente junto ao Departmento de Cirurgia*. Rosen M. A Simple Artificial Implantable Sphincter. *Bristish Journal of Urology,* v. 48, p. 675-

Sajadi KP & Terris MK. Artificial Urinary Sphincter, 17p. Disponível em

Schiavini JL et al. Our Experience Using the Periurethral Constrictor, a Simplified Silicone-

Schiavini JL, Da Silva EA, Toledo JS, Damião R, Dornas MC, Resende Jr. JAD. Our

Schiavini, João Luiz ; Resende Júnior, José Anacleto Dutra de; Barros, Cesar Borges . Reply.

Schiavini JL, Dutra de Resende Júnior JA, Dornas MC, Da Silva EA, Damião R. Tratamento

Scott FB et al. Treatment of Urinary Incontinence by Implantable Prosthetic Sphincter.

Shellock F, *MR Imaging of Metallic Implants and Materials: A Compilation of the Literature,* AJR,

Satisfaction and Criteria for Success. *Joumal of Urology* 1996; 156:1975-80. Montague DK, Angermeier KW, Paolone DR. Long-term continence and patient satisfaction

Incontinence and the Artificial Urinary Sphincter A Long-term Study of Patient

after artificial sphincter implantation for urinary incontinence after prostatectomy. *J* 

prostatectomia radical por meio da implantação do esfíncter artificial AMS 800. São Paulo, 2003. *Tese apresentada à Faculdade de Medicina da Universidade de São Paulo para* 

http://www.emedicine.com/med/topic3019.htm. Acesso eletrônico em: 21 de

made Device in the Male Urinary Incontinence (Abstract). *SIU Centennial* 

experience using the Periurethral Constrictor, a simplified silicone made device in the male urinary incontinence (Abstract). Urology, 70 (Supplement 3A): 36, 2007. Schiavini, João Luiz ; Damião, Ronaldo ; Resende Júnior, José Anacleto Dutra de; Dornas,

Maria Cristina ; Cruz Lima da Costa, Danilo Souza ; Barros, Cesar Borges . Treatment of Post-prostate Surgery Urinary Incontinence With the Periurethral Constrictor: A Retrospective Analysis. Urology (Ridgewood, N.J.) JCR, v. 75, p.

da incontinência urinária pós-prostatectomia radical com o constritor periuretral: análise retrospectiva de 30 casos (Abstract). Actas Urológicas Españolas

urinary incontinence: the test of time. *Braz J Urol*. 2000;26:415-417.

Mundy A. Artificial Sphincters. *British Journal of Urology,* v. 67, p. 225-9, 1991.

bone-anchored male sling. Eur Urol 47: 237-42, 2005.

ROSNER B. Fundamentals of Biostatistics. 2nd ed. Boston: PWS Publishers.

Urology (Ridgewood, N.J.) JCR, v. 75, p. 1492-1493, 2010.

(Suplemento), vol. 32 (6): 218, 2008.

*Urology*, v. 1, p. 252-9, 1973.

*Urol*. 2001;166.

80, 1976.

setembro de 2007.

1488-1492, 2010.

outubro 1988.

*Celebration*, Paris, 2007.

occlusive pressure of the system—once the presence of a self-sealing valve permits suitable readjustments through simple transcutaneal injections at any time on an outpatient basis, which makes the overall procedure safer and less expensive by avoiding unnecessary surgical reviews. In the case of the valves, we verified that the leakages were inadvertedly caused by needle perforations of the edge of the valve (where the silicone is thin) during the activation of the device. As a result of this, a project alteration of the valve that greatly diminished this risk was performed, and there was no occurrence of any other improper functioning of the device afterward.

The periurethral constrictor may also be an important option in the treatment of sphincteric urinary incontinence in elderly, parkinsonian, and hemiplegic patients who have suffered cerebral vascular accident or other conditions that contribute to the decrease of manual dexterity (which would prevent the manipulation of the artificial sphincter's mechanism). Another indication would be for incontinent patients who have sustained sphincter injury with bladder atony, which can benefit from the use of the device for staying dry and voiding by intermittent catheterization.

Moreover, the low cost of the periurethral constrictor is also an important characteristic in its favor when compared with the already established AMS 800. The rates of efficacy that are apparently similar between both devices and the constrictor's lower cost may encourage its use in all cases of postprostate surgery urinary incontinence where economic aspects are an important variable to be considered, including those where the artificial sphincter may also be indicated but its high cost prevents its use.

#### **4. References**


occlusive pressure of the system—once the presence of a self-sealing valve permits suitable readjustments through simple transcutaneal injections at any time on an outpatient basis, which makes the overall procedure safer and less expensive by avoiding unnecessary surgical reviews. In the case of the valves, we verified that the leakages were inadvertedly caused by needle perforations of the edge of the valve (where the silicone is thin) during the activation of the device. As a result of this, a project alteration of the valve that greatly diminished this risk was performed, and there was no occurrence of any other improper

The periurethral constrictor may also be an important option in the treatment of sphincteric urinary incontinence in elderly, parkinsonian, and hemiplegic patients who have suffered cerebral vascular accident or other conditions that contribute to the decrease of manual dexterity (which would prevent the manipulation of the artificial sphincter's mechanism). Another indication would be for incontinent patients who have sustained sphincter injury with bladder atony, which can benefit from the use of the device for staying dry and voiding

Moreover, the low cost of the periurethral constrictor is also an important characteristic in its favor when compared with the already established AMS 800. The rates of efficacy that are apparently similar between both devices and the constrictor's lower cost may encourage its use in all cases of postprostate surgery urinary incontinence where economic aspects are an important variable to be considered, including those where the artificial sphincter may also

Appell RA. Assessment and therapy for voiding dysfunction after prostatectomy. Curr Urol

Carson III. Urologic prostheses : the complete practical guide to devices, their implantation,

Castle EP, Andrews PE, Itano N, et al. The male sling for postprostate surgery incontinence:

Cespedes RD et al. Collagen Injection Therapy for Posprostatectomy Incontinence. *Urology,*

Chao r & mayo ME. Incontinence after radical prostatectomy: detrusor or sphincter causes. J

Foley FB. An Artificial Sphincter: a New Device and Operation for Control of Enuresis and

Hussain M et al. The Current Role of the Artificial Urinary Sphincter for the Treatment of

Klinjin AJ, Hop WCJ, Mickish G, Schroder FH, Bosch JLHR. The artificial urinary sphincter

Kuznetsov DD, Kim HL, Steinberg GD, Bales GT. Comparison of artificial urinary sphincter

in men incontinent after radical prostatectomy: 5-year actuarial adequate function

and collagen for the treatment of postprostatectomy incontinence. *Urology*.

and patient follow up. *New Jersey : Humana Press,* 309p, 2002.

Urinary Incontinence. *Journal of Urology,* v. 58, p. 250-4, 1947.

Urinary Incontinence. *Journal of Urology*, v. 174, p. 18-24, 2005.

mean follow-up of 18 months. *J Urol*. 2005;173:1657-1660.

functioning of the device afterward.

by intermittent catheterization.

**4. References** 

be indicated but its high cost prevents its use.

Rep 8: 175-8, 2007.

v. 54, p. 597-602, 1999.

Urol 154: 16-8, 1995.

2000;56:600-603.

rate. Br J Urol 82: 530-3, 1998.


**17** 

*Brazil* 

**Continent Urinary Diversions in Non Oncologic** 

Urinary diversion is a detour of the urinary tract. It may be necessary in different scenarios and can either be continent or incontinent, catheterisable or orthotopic. Pathological situations which may demand a urinary diversion are varied and include anatomical, physiological, congenital and traumatic causes, e.g. urethral stenosis and partial or complete urethral disruption; bladder dysfunction secondary to radiotherapy or congenital pathologies (posterior urethral valve, Prune-Belly Syndrome, epispadias, bladder extrophy,

The treatment has essentially four main goals: preservation of the upper urinary tract, urinary continence, adequate reservoir emptying and avoidance of urinary tract infections [4]. With the continued development of less invasive treatments for almost all urological pathologies (including severe bladder dysfunction) surgical urinary diversion can be

Urinary diversion can be classified as either continent or incontinent. Continent urinary diversion refers to a reservoir which can be emptied through clean intermittent catheterization (CIC). Incontinent diversion refers to situations where a continuous free urinary flow through an interposed intestinal segment pours into a collecting bag [2].

Although being a realistic alternative to treat patients with a compromised bladder or urethra, one must be aware of the inherent challenges and possible complications related to urinary diversion. This encompasses not only the surgical aspects, but also the post

We review pre and post operative aspects related to the continent urinary diversion

The ultimate aim in reconstruction of the lower urinary tract in patients with adequate storage function is to attain continence. Adequate emptying can be achieved with consideration of manual dexterity, cognitive capability and patient choice. The options to create a continent or incontinent urinary system can range from long-term catheterisation,

commonly used in benign pathologies and the current literature pertaining to this.

intermittent cathterisation or diversion – incontinent, or continence cutaneous.

cloaca); neurogenic bladder and idiopathic bladder dysfunction [1-3].

currently considered the end treatment for these patients [2,4,5].

operative care and management of complications.

**2. Selection criteria for urinary diversion** 

**1. Introduction** 

**Situations: Alternatives and Complications** 

Ricardo Miyaoka and Tiago Aguiar

*Division of Urology, State University of Campinas, Sao Paulo,* 

