**1. Introduction**

262 Urinary Incontinence

Whiteside JL, Weber AM, Meyn LA, Walters MD. (2004) Risk factors for prolapse recurrence

Zorn KC, Daigle S, Belzile F, Tu le M, (2005) Embolization of a massive retropubic

hemorrhage following a tension-free vaginal tape (TVT) procedure: case report and

after vaginal repair. Am J Obstet Gynecol 191(5):1533-8.

literature review. *Can J Urol* 12(1):2560-3.

There are few long-term medical conditions and non-fatal injuries that are so inconvenient as the urinary incontinence in its various degrees. This situation effect the social life and there are consequences for the economic impact of this clinical condition in patients and health services.

The direct costs associated with urinary incontinence is related to aspects such as diagnostic tests, doctor visits, surgery, use of diapers, and others. Among the indirect costs can include the time available for patients and friends to care of incontinent patients, and the loss of productivity for the individual hours away at work. The worsening quality of life of the patient is considered an intangible cost, difficult to measure in monetary terms, but which constitutes an integral aspect of urinary incontinence.

Among the various causes of urinary incontinence, sphincter incompetence is one of the most common (Mundy, 1991). Fortunately, most patients with sphincter incompetence have simple stress incontinence, which usually responds well to one of several procedures for suspension of the bladder neck or urethra. However, surgery does not work without implants as favorably for the treatment of severe urinary sphincter, where the loss of urethral support is irrelevant (Mundy, 1991). In these circumstances, the best form of treatment is still the deployment of devices performing a specific function that compensates constrictor malfunction of the urethral sphincter (Hussain et al. 2005; Mundy, 1991; Schiavini et al. 2007; Vilar et al. , 2004).

The initial treatment of urinary incontinence with urethral devices date from 1947, when Foley described the first artificial sphincter (Foley, 1947). According to its proposal, the penile urethra was exteriorized, involved with the foreskin and, after healing, the device was placed around the urethra. This device consisted of a tube connected to a syringe, the patient carried in his pocket, and when wanted to maintain continence, insert some fluid that would exert pressure through the syringe. Foley's method fell into disuse due to the high incidence of urethral injuries.

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 265

sphincter in Latin America. Meanwhile, the Constrictor has provided preliminary efficacy

a)

b) Fig. 1. a) AMS 800, a device of 3 parts - body, balloon and pump. b) Operating mode of the

AMS 800 (Permission by American Medical Systems®)

results similar to the AMS 800, on a smaller device cost about 16 times.

In 1973, Scott and colleagues, based on the idea of Foley, have created a toilet model totally implantable device, the AMS 721, which was modified and optimized by Rosen, 1976 (Rosen, 1976, Scott et al., 1973). This device allowed compression of the bulbar urethra by inflating the device. Due to poor results, the device also fell into disuse.

Changes were made in the initial design and the most important was the use of a balloon to regulate the pressure valve in place.

Later models also incorporated an entirely new body of silicon, rather than a body of Dacron ®. A decrease in the number of components and connections resulted in the current AMS 800 (Fig. 01a), a device consisting of 3 parts (Hussain et al., 2005).

The AMS 800 is a body-shaped strap that is placed around the bladder neck or bulbar urethra. This body is connected to a balloon pressure regulator via a control pump, located in the scrotum of the patient. The whole system is filled with saline, hydraulic operation. The pressure in the system and therefore the strength of the occlusive balloon body is determined by the throttle, being maintained in the system except when the pump is activated voluntarily by patients who do not account for intermittent catheterization. This activation provides the rapid emptying of saline in the body, which fluid is directed to the balloon pressure regulator, momentarily removing the occlusive force of the body and allowing urination by the patient (Fig. 01b). The body is kept empty for long enough (2-3 min) so that urination is complete before returning to gain momentum due to the return of occlusive saline (Hussain et al. 2005; Mundy, 1991).

Urinary incontinence after prostate surgery represents a social problem and public health, patient and burdening the state with direct and indirect costs and affect the quality of life of patients. The AMS 800 is the best treatment for the patients with severe sphincter incontinence, but preliminary data from the Constrictor Inflatable Periurethral are encouraging (Kuznetozov et al., 2000, Montague et al. 2001; Schiavini et al., 2007).

Treatments such as collagen injections and the periurethral sling men do not appear as effective alternatives for long-term treatment of severe forms of this type of incontinence. Despite the long history of use, collagen injections are associated with success rates that generally do not exceed 40% cure rate. Due to the metabolism of collagen in the body, there is a gradual decrease in cure rates associated with the technique. This transient effectiveness usually takes the need for applying multiple injections on each patient, increasing the treatment without increasing the rates of long-term success (Carson, 2002, Cespedes et al., 1999, Kuznetsov et al., 2000).

The male sling appeared as a possible treatment for patients with sphincter incontinence after prostate surgery. However, the results were effective only in patients with mild to moderate incontinence (Castle et al., 2005). Sahaja & Terris, 2006, also pointed out that the male sling would not be as effective as a device with more physiological action, such as the artificial sphincter. For the structural similarity between the body of the AMS 800 and the Constrictor, this reasoning could be extended to the Constrictor.

Another aspect to be considered is that, despite their recognized efficacy, the greater structural complexity of the AMS 800 has a direct impact on their high cost (Mundy, 1991). This is one of the reasons that explain the low access to this device for patients with urinary

In 1973, Scott and colleagues, based on the idea of Foley, have created a toilet model totally implantable device, the AMS 721, which was modified and optimized by Rosen, 1976 (Rosen, 1976, Scott et al., 1973). This device allowed compression of the bulbar urethra by

Changes were made in the initial design and the most important was the use of a balloon to

Later models also incorporated an entirely new body of silicon, rather than a body of Dacron ®. A decrease in the number of components and connections resulted in the current

The AMS 800 is a body-shaped strap that is placed around the bladder neck or bulbar urethra. This body is connected to a balloon pressure regulator via a control pump, located in the scrotum of the patient. The whole system is filled with saline, hydraulic operation. The pressure in the system and therefore the strength of the occlusive balloon body is determined by the throttle, being maintained in the system except when the pump is activated voluntarily by patients who do not account for intermittent catheterization. This activation provides the rapid emptying of saline in the body, which fluid is directed to the balloon pressure regulator, momentarily removing the occlusive force of the body and allowing urination by the patient (Fig. 01b). The body is kept empty for long enough (2-3 min) so that urination is complete before returning to gain momentum due to the return of

Urinary incontinence after prostate surgery represents a social problem and public health, patient and burdening the state with direct and indirect costs and affect the quality of life of patients. The AMS 800 is the best treatment for the patients with severe sphincter incontinence, but preliminary data from the Constrictor Inflatable Periurethral are

Treatments such as collagen injections and the periurethral sling men do not appear as effective alternatives for long-term treatment of severe forms of this type of incontinence. Despite the long history of use, collagen injections are associated with success rates that generally do not exceed 40% cure rate. Due to the metabolism of collagen in the body, there is a gradual decrease in cure rates associated with the technique. This transient effectiveness usually takes the need for applying multiple injections on each patient, increasing the treatment without increasing the rates of long-term success (Carson, 2002, Cespedes et al.,

The male sling appeared as a possible treatment for patients with sphincter incontinence after prostate surgery. However, the results were effective only in patients with mild to moderate incontinence (Castle et al., 2005). Sahaja & Terris, 2006, also pointed out that the male sling would not be as effective as a device with more physiological action, such as the artificial sphincter. For the structural similarity between the body of the AMS 800 and the

Another aspect to be considered is that, despite their recognized efficacy, the greater structural complexity of the AMS 800 has a direct impact on their high cost (Mundy, 1991). This is one of the reasons that explain the low access to this device for patients with urinary

Constrictor, this reasoning could be extended to the Constrictor.

encouraging (Kuznetozov et al., 2000, Montague et al. 2001; Schiavini et al., 2007).

inflating the device. Due to poor results, the device also fell into disuse.

AMS 800 (Fig. 01a), a device consisting of 3 parts (Hussain et al., 2005).

regulate the pressure valve in place.

occlusive saline (Hussain et al. 2005; Mundy, 1991).

1999, Kuznetsov et al., 2000).

sphincter in Latin America. Meanwhile, the Constrictor has provided preliminary efficacy results similar to the AMS 800, on a smaller device cost about 16 times.

a)

Fig. 1. a) AMS 800, a device of 3 parts - body, balloon and pump. b) Operating mode of the AMS 800 (Permission by American Medical Systems®)

b)

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 267

The relative simplicity of the Constrictor apparently does not interfere with its effectiveness. Studies of the groups of Dr. Salvador Vilar and Dr. João Schiavini Constrictor present with continence rates of around 85% during treatment, as mentioned ahead. Moreover, the Constrictor was also able to provide some patients voiding spontaneously, especially in adults with urinary incontinence after prostate surgery sphincter. Even in cases where intermittent catheterization was used, the rate of patient satisfaction were generally high

In 2000, Lima and colleagues from the Hospital Infantil Manoel Almeida, Federal University of Pernambuco - Recife, presented results on the use of inflatable Periurethral Constrictor for the treatment of urinary incontinence secondary to myelomeningocele. The 24 patients (14 men and 10 women) were in the age group 5 to 42 years, and were followed for an average of 4.2 years (1-84 months). Concomitant with the deployment of the device, 21 of these patients underwent cystoplasty to increase with the use of Deepithelialize colon. Twenty-one patients had a good result with the device in addition to being functional continents, giving a success rate of 87.5%. In 3 (12.5%) cases, the device was removed due to the occurrence of erosion and infection. At the end of the study, the authors stated that the use of inflatable Periurethral Constrictor would be a safe and effective in the treatment of long-term causes of neurogenic urinary incontinence (Lima et

In 2004, Vilar and colleagues presented a second study group related to the use of Constrictor Inflatable Periurethral the surgical treatment of urinary incontinence in 42 children (29 boys and 13 girls) with a mean age of 10.2 years (3 to 17 years ). The group consisted of 29 neurogenic patients, 12 with bladder exstrophy and 1 with megalouretra. Concomitant with the deployment of the device, augmentation cystoplasty was performed in 34 patients. Patients were followed for an average of 5.2 years (4 to 104 months). In 25 patients in the neurogenic group the device was functional and provided continence, which represented a rate of continent patients during treatment of 86%. In 4 (14%) patients, the device was removed due to erosion (3) and infection (1). The patient was continent and megalouretra urinated spontaneously. In the exstrophy group, 10 patients had their devices explanted due to erosion and incontinence. Only two kept the device and performed intermittent catheterization. The authors concluded that the Constrictor Periurethral would be a long-term alternative, safe and effective for the surgical treatment of urinary incontinence cause neurogenic sphincter in children. Like previously reported for other implants, the authors emphasized that the device should be used with caution in patients

In 2007, Schiavini & Resende Jr and colleagues, University Hospital Pedro Ernesto, Rio de Janeiro, showed their initial experience with the use of inflatable Periurethral Constrictor.

In this study, eighteen patients had urinary incontinence after radical retropubic prostatectomy, and five were previously submitted to procedures for the treatment of

(Vilar et al. 2004; Schiavini et al., 2007). The main results are described ahead.

**2.1 Constrictor treatment in patients with neurogenic urinary incontinence** 

al., 2000).

with bladder exstrophy (Vilar et al., 2004).

**2.2 Post-prostate surgery urinary incontinence.** 
