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| NIRAMAYAM ( Newsletter of Batra Hospital & MRC)
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 Introduction............. |
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The artificial urinary sphincter has completely changed the quality of life for thousands of people with refractory incontinence not
amenable to any other treatment approach. Foley is credited for introducing the first artificial urinary sphincter (AUS) in 1947.
This had an internal cuff placed around penile urethra and an external valve and a syringe kept in patient trouser but complications
like necrosis and fistula formation lead to its discontinuation. The modern AUS introduced initially by Scott and co-workers in
1973 is a complete internal device with three components. Cuff, which encircle around bulbous urethra, reservoir implanted in
prevesical space and a flow resister pump for initiating voiding placed in the scrotal dartos pouch for patient convenience.
The current device introduced by American Medical System (AMS 800) is a fluid filled, wear resistant, biocompatible,
silicone elastomer, which works hydraulically with activation and de-activation features.
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| Indications............. |
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Indications for AUS placement fall in one of five groups: neuropathic bladder dysfunction (congenital), post-prostectomy
incontinence, failed anti-stress incontinence surgery, congential anomalies and trauma. The absolute requirements of a patient
requiring AUS placement are normal upper extremity motor skills, no UTI, normal detrusar functions (urodynamic study)
with or without medication and irreversible sphincteric damage.
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| Experience............. |
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Our patient 65 years old hypertensive male developed total incontinence immediately after TUR-P procedure done at another
institute in 2003. Day and night dribbling caused social and mental disturbance leading to depression and psychosis. All kind
of pharmacological and physiotherapy (Bio-feedback) measures were tried for three years before he was referred to Batra Hospital
& MRC for definitive management. Digital rectal examination revealed flat prostate with normal and sphincter tone. Routine
investigations were normal as was the serum PSA levels. Urodymamic study(CMG) and imaging study revealed normal bladder
capacity and functions with normal caliber urethra but no sphincter action(Fig 1).
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| Fig. 1: VCUG study revealing normal bladder morphology and a-sphincteric urethra |
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Positive urethra cultures were rendered sterile after appropriate antibiotics. Psychic consultation
was sought in view of his prolonged depression. Initial cysto-urethroscopy revealed resected sphincter area distal to veru anteriorly
and laterally. After adequate bowel and skin preparation the patient was taken up for AUS placement under combined
spinal-epidural anesthesia. All the three components of AUS were interconnected with kink resistant color-coded silicone
tubing (Fig 2a & 2b). |
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| Fig. 2a : Artificial Urinary System components placed at sites shown |
Fig. 2b : Silicone cuff around bulbous urethra |
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The AUS was immediately de-activated for a period of 6 weeks to allow peri-uretheral edema to settle
down and tissue healing. Post-operative antibiotic prophylaxis for seven days allowed uneventful healing. Patient was then
discharged to follow-up after 6 weeks. Again positive urine cultures were rendered sterile and cuff activated by giving a firm,
forceful squeeze to pump sited in hemo-scrotum. Follow-up VCUG revealed functioning cuff maintaining continence (fig 3a)
and allowing voiding by gentle squeeze to pump (fig 3b). |
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| Fig. 3a : VCUG showing cuff inflated maintaining continence |
Fig. 3b : deflated allowing voiding |
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Reported complications like infection, erosion and mechanical
malfunction were not reported I our patient till 3-months follow-up.
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| Glossary............. |
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CMG : cystometrogram;
PSA : prostate specific antigen;
UTR-P : transurethral resection of prostate;
UTI : urinary tract infection;
VCUG : voiding cystography.
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Establishment of Gurgaon Centre
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of Batra Hospital & Medical research Centre
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BHMRC entered into an agreement with powergrid Corporation of India Ltd (PGCIL) to setup a Medical Centre at the PGCIL
Residential Complex, Sector 43, Gurgaon, Haryana. There are 600 families in and around the Medical Centre and the major
beneficiaries would be the employees of PGCIL and their families. There are residential complexes around this area that are
also allowed to make use of this facility being established by BHMRC.
Clinical services at the medical centre comprise of emergency services, general and special OPD services, minor procedures and
miscellaneous services during Phase-I that is expected to start in September 2006. Consultants from all specialties would be
visiting the centre at scheduled timings to provide comprehensive multi-specialty services to the beneficiaries. In Phase-II,
X-ray procedures, Dental and Physiotherapy services will be provided.
In the mean time, Batra Hospital has started a temporary centre in June 2006 in a make-shift accommodation provided by the
PGCIL that is providing consultation and referral services.
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