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    AUS placement: Updated perineal approach

    Joshua A. Broghammer, MDJoshua A. Broghammer, MD Sean Elliott, MD, MSCommentary by Sean Elliott, MD, MS

    Dr. Broghammer is associate professor of urology and Dr. Smelser is a urology resident, University of Kansas Medical Center, Kansas City.

     

    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.

    Urologists demonstrate several techniques to help the occasional AUS implanter avoid complications.
     

    Dr. Elliott: Dr. Broghammer’s video demonstrates several techniques that can help the occasional implanter avoid dreaded complications of infection, urethral erosion, and pump migration.

    First, he uses a “no-touch” technique popularized originally for penile implant insertion. The entire field is covered in Ioban in order to avoid the introduction of skin-level bacteria into the surgical site. Fortunately, infection rates are lower after AUS insertion (about 2%) than after penile implant insertion. However, placing an Ioban only takes a minute and it may help.

    Second, the video nicely demonstrates a technique of irrigating through the urethral meatus, alongside the urethral catheter in order to interrogate for a urethral injury. Prompt recognition of a urethral injury means that the cuff is not inserted and a urethral erosion is avoided.

    Finally, the video demonstrates, similar to the technique of Dr. Peterson, a lower abdominal incision for the pressure-regulating balloon and pump placement. Hegar dilators are used to make a narrow tunnel to the scrotum for pump placement; this minimizes the risk of pump migration even though no purse string suture is used to hold to pump in place.

    Dr. Hotaling: Dr. Broghammer demonstrates clear use of a reproducible technique to safely and efficiently place an AUS. He focuses on setting up the key maneuvers of the surgery to efficiently place the cuff, pump, and reservoir while minimizing the chances of infection. He makes excellent use of the no-touch technique, a saline peri-catheter retrograde urethrography to evaluate for urethral injury and use of Hegar dilators to develop space for the pump. Further, he illustrates clear and reproducible anatomic landmarks for this procedure.

    More AUS videos:

    AUS placement: Key steps in the Duke technique

    AUS placement: The 30-minute technique
     

    James M. Hotaling, MD, MSSection Editor James M. Hotaling, MD, MS Dr. Hotaling is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.
     

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