**2.2.3 Exclusion criteria**


bladder neck strictures. In all patients, the body of the device was placed around the bulbar urethra, with activation of the device after 8 weeks. Patients were followed from 6 to 36 months. For the authors, successful treatment was predefined as the need to use a diaper

The complete urologic evaluation was performed, including urine analysis, ultrasonography, cystography and urodynamic studies before to submit the patients to the surgery, respecting

 Be in good general health prior to participation in the study, no significant clinical abnormalities determined by: clinical history, physical examination, blood chemistry, blood count, urinalysis (the results of biochemical tests or hematology or urinalysis laboratory do not contain references, the patient may be included only if the researcher

 History of significant disease (ex. cardiovascular, pulmonary, gastrointestinal, hematological, neurological, degenerative, hormonal, autoimmune or cancer).

Any situation that increases the possibility of infection / erosion after body contact

 Any condition, which in the opinion of the investigator, may interfere with the patient participation in the study (ex. difficulty of meeting the requirements of the study, attend appointments, or any other situation that may affect the response of the questionnaire

Patient expected to undergo surgery during the study period, which may affect the

Patient undergone previous surgical treatment for the treatment of sphincter

device with the bulbar urethra (ex. sequelae of prior radiotherapy);

until the day - social continence, together with patient satisfaction.

Diagnosis of sphincter incontinence after prostate surgery;

finds that the changes are not clinically significant); Informed Consent in writing and signed by the patient.

Detrusor overactivity unresponsive to clinical treatment.

Use of drugs that interfere with bladder function;

History of allergenicity to foreign bodies or silicone;

 History of drug abuse in the last two years; Risk that prevents surgical surgery / anesthesia;

on quality of life by the patient);

outcome;

incontinence.

the inclusion and exclusion criteria previously established, as described below.

**2.2.1 Preoperative evaluation** 

**2.2.2 Inclusion criteria** 

18 years or more;

**2.2.3 Exclusion criteria** 

Low compliance bladder;

Severe urethral stenosis,

Presence of active infection;

History of psychological instability;

Men;

Fig. 3. Urologic Evaluation

#### **2.3 Surgical approach and intra-operative procedures**

The patient is subjected to anesthesia in the operating room after evaluation by the anesthesiologist. Prophylaxis with intravenous antibiotics (3rd generation cephalosporin) will be held 30 minutes before starting surgery. Will be held genital shaving and antisepsis genital at least 5 minutes and drapes are placed.

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 271

Fig. 5. Details of the valve implantation at the subdartic space of the scrotum.

conjunction with the measurement of pressure inside the device.

The urethral catheter can be withdrawn on the 1st postoperative day. Activation of Inflatable Periurethral Constrictor should be held approximately 8 weeks (at least 6 and at most 12 weeks) after implantation, when a urodynamic study should be performed in

To enable Inflatable Periurethral Constrictor, you should use a butterfly type intravenous scalp, 25G to 27G, previously filled with sterile saline, and pyrogen, to puncture the valve. The puncture should be done in the center of the constrictor valve in 90-degree angle, avoiding the edges of this valve, where the silicon is thinner, not to damage it. Must be injected sterile saline and pyrogen in an amount sufficient to produce continence, even

**2.4 Post operative care** 

Ureteroscopy with internal urethrotomy was performed when it was not possible to place a bladder catheter preoperatively.

To implement the Constrictor Inflatable Periurethral around the bulbar urethra, the surgical access of up to 10cm in the perineal raphe, with the developer in the lithotomy position. The muscle fibers bulb-cavernous must be separated in the longitudinal direction, and the bulbar urethra dissected easily visible and later by creating the space for placing the constriction around her body (Fig-4).

Fig. 4. Details of the constrictor cuff implantation around the bulbar urethra, after the dissection and separation of the bulbospongiosus muscle fibers.

The pipe must be routed through the subcutaneous space and the valve implanted in the suprapubic region or subdartic within the scrotum, where it can be punctured (Fig-5).

The Constrictor Inflatable Periurethral should have your air completely removed before being introduced into 2 ml of pyrogen-free saline. Meticulous haemostasis is essential to reduce risk of haematoma formation.

Ureteroscopy with internal urethrotomy was performed when it was not possible to place a

To implement the Constrictor Inflatable Periurethral around the bulbar urethra, the surgical access of up to 10cm in the perineal raphe, with the developer in the lithotomy position. The muscle fibers bulb-cavernous must be separated in the longitudinal direction, and the bulbar urethra dissected easily visible and later by creating the space for placing the

Fig. 4. Details of the constrictor cuff implantation around the bulbar urethra, after the

The pipe must be routed through the subcutaneous space and the valve implanted in the suprapubic region or subdartic within the scrotum, where it can be punctured (Fig-5).

The Constrictor Inflatable Periurethral should have your air completely removed before being introduced into 2 ml of pyrogen-free saline. Meticulous haemostasis is essential to

dissection and separation of the bulbospongiosus muscle fibers.

reduce risk of haematoma formation.

bladder catheter preoperatively.

constriction around her body (Fig-4).

Fig. 5. Details of the valve implantation at the subdartic space of the scrotum.

#### **2.4 Post operative care**

The urethral catheter can be withdrawn on the 1st postoperative day. Activation of Inflatable Periurethral Constrictor should be held approximately 8 weeks (at least 6 and at most 12 weeks) after implantation, when a urodynamic study should be performed in conjunction with the measurement of pressure inside the device.

To enable Inflatable Periurethral Constrictor, you should use a butterfly type intravenous scalp, 25G to 27G, previously filled with sterile saline, and pyrogen, to puncture the valve. The puncture should be done in the center of the constrictor valve in 90-degree angle, avoiding the edges of this valve, where the silicon is thinner, not to damage it. Must be injected sterile saline and pyrogen in an amount sufficient to produce continence, even

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 273

The recommendations for postoperative monitoring are in the figure below (Fig-7).

**2.6 Observations and measurements postoperative** 

Fig. 7. Urologic Evaluation Postoperative.

during sudden increase in abdominal pressure, such as episodes of coughing, but allows good urinary flow, without causing urinary retention.

During the activation step, the clinician must be careful that the needle is inserted into the valve without excessive force, which could cause bending at the end of the needle and damage to the silicone septum during their re-treatment, thus undermining the proper functioning valve device.

In addition, the use of large-caliber needles can destroy the valve.

Fig. 6. Periurethral constrictor's activation by injection of saline solution through the selfsealing valve located at the scrotum. After activation, the patient had a good urine flow and achieved urinary continence.

#### **2.5 Efficacy variables**

The subjective and objective efficacy of the intervention was determined monthly in the first year and quarterly by the end of the third year (final visit) based on clinical results obtained in the patient Pad Test and questionnaires.

The questionnaires validated quality of life WHOQOL (World Health Organization - Quality of Life) and ICIQ-SF (International Consultation on Incontinence Questionnaire - Short Form) were used as an instrument of measurement.

### **2.6 Observations and measurements postoperative**

272 Urinary Incontinence

during sudden increase in abdominal pressure, such as episodes of coughing, but allows

During the activation step, the clinician must be careful that the needle is inserted into the valve without excessive force, which could cause bending at the end of the needle and damage to the silicone septum during their re-treatment, thus undermining the proper

Fig. 6. Periurethral constrictor's activation by injection of saline solution through the selfsealing valve located at the scrotum. After activation, the patient had a good urine flow and

The subjective and objective efficacy of the intervention was determined monthly in the first year and quarterly by the end of the third year (final visit) based on clinical results obtained

The questionnaires validated quality of life WHOQOL (World Health Organization - Quality of Life) and ICIQ-SF (International Consultation on Incontinence Questionnaire -

good urinary flow, without causing urinary retention.

In addition, the use of large-caliber needles can destroy the valve.

functioning valve device.

achieved urinary continence.

in the patient Pad Test and questionnaires.

Short Form) were used as an instrument of measurement.

**2.5 Efficacy variables** 

The recommendations for postoperative monitoring are in the figure below (Fig-7).

Fig. 7. Urologic Evaluation Postoperative.

Treatment of Post-Prostatic Surgery Stress Urinary Incontinence 275

iatrogenic complications that occurred during dissection of the bulbar urethra. Thus, 19 patients with functional implants represented a success rate of 86%, during an mean follow

In the update made in 2010, and Schiavini & Resende Jr and colleagues, 30 patients were evaluated and followed up for a mean of 42.1 months (range, 13-72). In 22 patients (73.3%), the implanted devices were functional, 16 patients (53,3%) were completely dry, and 06 (20%) required 1 pad per day; 20 voided spontaneously, and 2 performed intermittent catheterization. Among them, 7 patients were submitted for ambulatory review—within 2 weeks of the activation of the device—to increase the occlusive static pressure of the cuff (range of volume added, 0.4-1.7 mL); and 4 were submitted for surgical exchange of the valve because of leakage of saline solution. Despite these occurrences, all of these patients

The main complications were urethral cuff erosion in 4 patients (13.3%) and infection in 3 patients (10%), leading in these cases to early and complete removal of the devices. An eighth patient remained incontinent after the device reactivation because of detrusor hyperreflexia. In this series, there was no occurrence of any other major complications.

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

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

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

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,

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

neurogenic urinary incontinence (Lima SVC, et al. 2000; Vilar FO, et al. 2004).

up of 28 months (6 to 50 months). (Schiavini et al, 2007).

claimed they were very satisfied with the results.

increase in long-term cure (Cespedes.1999; Kuznetsov et al. 2000).

**3. Comment and conclusion** 

(Castle et al. 2005; Montague et al. 2001).

there were no new cases of erosion and infection.
