AUS placement: Key steps in the Duke technique

Author(s):

Andrew C. Paterson, MD,Uwais B. Zaid, MD

This video, from Andrew C. Paterson, MD, and Uwais B. Zaid, MD, describes a technique for the placement of the male bulbar artificial urinary sphincter.

Section Editor’s note:‘Y’tube, a video section of UrologyTimes.com, is a resource for urologists and other clinicians who focus on men’s health. ‘Y’tube covers surgical aspects of a variety of men’s health issues with the ultimate goal of accumulating a library of videos to serve as a reference. Here, three high-volume implanters demonstrate how precise setup and preparation can facilitate a rapid, minimally invasive, and successful artificial urinary sphincter (AUS) placement. Dr. Peterson demonstrates a unique method for cuff sizing, while Dr. Broghammer demonstrates another technique to optimize this crucial step of the procedure. Dr. Elliott displays a remarkable 30-minute AUS placement that is facilitated through a number of time-saving maneuvers. All surgeons demonstrate the importance of sharp dissection and clear exposure of the urethra.

This video describes a technique for the placement of the male bulbar artificial urinary sphincter (AUS).

Dr. Elliott: Dr. Peterson is one of the highest volume AUS implanters in the country, and his institution, Duke Urology, has been a leader in AUS placement for 30 years. Several steps in the video deserve special mention.

First, the method of measuring the urethral circumference and selecting the proper cuff size is a common source of anxiety for the occasional implanter. If the cuff is too tight, then retention, atrophy, or erosion may occur. If it is too loose, then incontinence persists. Dr. Peterson uses an umbilical tape to measure the circumference of the urethra in order to avoid some of the imprecision that comes from the flexibility of the measuring tape included in the kit. He tends to use the measured size or downsize by 0.5 cm so as to ensure complete continence; others will upsize by 0.5 cm and warn the patients that they should tolerate a small amount of incontinence in order to avoid the complications of a tight cuff.

A lower abdominal incision is made for the pressure-regulating balloon and a long tunnel is made into the scrotum for the pump. Notice how Dr. Peterson takes care to keep this tunnel narrow; he doesn’t overdilate with the forceps nor does he stretch it with a finger. A narrow tunnel prevents cephalad pump migration.

Finally, and perhaps most uniquely, a long-standing tradition at Duke has been that the surgeons prepare their own implant on the back table. This is something I have avoided because I prefer to save time by making surgical progress as the scrub nurse is preparing the device components. However, Dr. Peterson is able to do this in less than 4 minutes and feels that it helps him ensure the quality of the implant.

Dr. Hotaling: Dr. Peterson’s video illustrates bentback retractors to facilitate exposure rather than a Lone Star or other retractor. This technique allows him to clearly define the anatomy in a bloodless plane and to visualize the corporal body and urethral edge, and come cleanly around the urethra. Using umbilical tape to size the urethral cuff provides an easy way of precise measurement.

The use of contrast in the device has been widely described over 30 years of AUS implants at Duke and may help to troubleshoot device malfunction. Although most surgeons do not prepare their own device, a thorough working knowledge of this process is essential to proper device function, and this serves as a helpful reference. Sharp dissection of the space of retzius facilitates minimal tissue disruption and bleeding during reservoir placement.