Male Incontinence

The way the procedure is done, the patient is brought to the operating room.

They are actually awake. Although, we do give sedation and local anesthetics, so they're very comfortable while we're doing the procedure.

What we do is we look for the specific landmarks.

So, we look for the tailbone, and then we identify the bones by feeling through the skin.

Once we've located the area where we believe the appropriate nerve root is, we actually take a small electrical conduction needle and place it through the skin that's been anesthetized and down into the opening in the bone, and that then sits down right alongside the nerve.

Once that's in place, we test it electrically and we take some X-ray pictures to make sure that we're in the right position.

Once we're sure that we're in the correct placement, we exchange this needle for an electrode that has four small contact points on it.

That actually again goes through the bone and sits down right alongside the nerve.

So, the nerve would be coming out kind of down in this area and that's what's going to give the electrical impulses to the nerve.

The patient wears this for one to two weeks.

It's connected to a little external wire that comes out of the skin, and the patient hooks it up to a small generator.

It looks sort of like a pager, and they keep a diary for us about their symptoms.

When they come back in one to two weeks, if it looks like they've had a good response and an improvement in their symptoms, then what we do is connect this lead to a small internal generator.

So, it's basically like a pacemaker battery, and that is put just under the skin kind of in the lower part of the back kind of above the hip.

It's very thin, and so for most patients they really don't even feel it unless they're pressing on it.

Then, this has a small set of computer chips in it that allows the patient to program the device and adjust it based on their symptoms.

This particular patient that had his surgery today was a patient who had undergone a radical prostatectomy for prostate cancer.

His prostate cancer was cured, but he was left with one of the unfortunate side effects that happen in a low percentage of people, and that is urinary incontinence.

He presented today to get an artificial urinary sphincter in place.

The prostate actually lies right next to what we call the genitourinary sphincter, which is the muscle that you use to control your urine.

So, sometimes after a prostatectomy or a prostate removal you can actually have an injury to that muscle, where patients start to lose control.

That can be variable, from just a little bit of leakage to really quite dramatic leakage with someone using anywhere from eight to 10 pads a day.

The incontinence that occurs is usually called stress incontinence.

This occurs when people are doing heavy activity.

They're lifting.

They're playing golf.

They're doing kind of the things in their day-to-day living.

Simply getting out of a chair can cause a leakage, so it can be quite debilitating.

It's difficult to go out to dinner if you're worried about having wet pants, changing multiple pads per day.

Car trips are often difficult or leaving the house for long periods of time. It can really change someone's life.

Basically, what we do is we make a small incision in the perineum, which is the space in between the legs, to locate the urethra or the tube that you pee through.

So, what we're looking at here is we've split the fat layer over top of the urethra, and we're just now getting into the muscle that surrounds the urethra. Last loop.

So, what we've essentially done here to start the case is we've made an incision through the perineum and dissected down through the subcutaneous fat.

We've spread open the bulbospongiosus muscle, which is the muscle used for ejaculatory function, to expose the urethra, which is this blue midline structure, which we also have the blue tape wrapped around.

This is the area where our artificial sphincter is gonna go and where we specifically size it and custom fit it to the patient's needs in terms of their degree of incontinence.

So, this is the cuff that we're going to place here in the patient.

This will provide the pressure support to help hold the urethra closed. Here you can see the cuff being put into place. We're just going to deploy this.

This is what the device looks like. You can see here the inflatable cuff is around.

There's tubing that we're gonna pass into the abdomen, so the patient can activate the device, but this is essentially gonna provide coaptation of the urethra in order for him to help maintain his continence.

What we're going to do now is just pack the wound with an antibiotic soaked sponge and then proceed to the abdominal portion of the operation. All right.

What we've basically done here is we've made a series of sharp incisions down to the muscle layer of the abdominal wall. We're then entering the extraperitoneal space, which is the space outside the sac that holds the intestines and the bladder.

We're just adjacent to the bladder.

We'll be putting the reservoir, which holds the fluid, in order to make the device function.

Again, same with the other incision.

We copiously irrigate this in order to prevent an infection.

What we have here is his device comes from ... this black and clear tubing comes from the reservoir.

This yellow tubing comes from the cuff.

We have a retractor or ring forceps in the scrotum right now, which is marking where we're gonna put our pump to.

So, we'll place this device, and then we'll make the connections. Here you can see the device has been implanted into the scrotum.

The pump has been subcutaneously tunneled down into the scrotum.

This is what the patient will manipulate in order to use the restroom. All right.

Now, what you can see here is we've made the connections and trimmed the tubing down, so it's an appropriate length.

We're going to release these connections and bury the tubing.

We'll pull the pump down into its appropriate spot within the scrotum, which you can see here, and the tubing disappears.

We'll then begin to close our incisions.

What we did today is we placed a small cuff around that urethra and then hooked it up to a device that goes into the scrotum, which we refer to as the pump.

So, when the patient needs to urinate, he simply squeezes that pump, releases the cuff around the urethra.

He's able to urinate. The device then resets, and he can go about his normal daily affairs, hopefully dry.

This is an example of the device. Here we have a reservoir, which goes into the patient's abdomen.

This stores the fluid to help make the device function.

What I've illustrated here with this red catheter is the urethra or the peeing tube, if you will.

We have a cuff or a balloon which goes around that.

By this device squeezing, this is what's gonna help provide the patient continence.

When the patient needs to urinate, this pump has been tunneled into his scrotum, in which case he just simply squeezes the base of this.

This will then release the cuff around his urethra.

He'll be able to urinate.

Then the device automatically resets without having to do any manipulation.