Single piece artificial urinary sphincter for secondary incontinence following successful repair of post traumatic urethral injury
A 14-year-old boy came to us with incontinence after post pelvic fracture-related urethral injury repair. He had suffered urethral injury in a road traffic accident 10-years-ago followed by staged urethral reconstruction. At the end of few months of urinary diversion, he had undergone urethral repair using abdominoperineal approach. Ten years following surgery, he was able to pass urine but he continued to dribble all the time. He had been on several modalities of medical management with no benefit. On examination, he had an abdominal and perineal scar of previous operation and deformed and scarred penile skin due to chronic use of condom catheter, leading to some tourniquet effect.\nThe renal function tests, urine routine, microscopy, and culture were normal. Ultrasound of the urinary tract revealed normal upper tracts and no post void residue. The post-operative micturating cystourethrogram (MCU) done 10 years after repair, revealed a normal capacity bladder. There was urinary leak at 200 ml, no vesicoureteric reflux, absence of urethral stricture, and no post void residual urine. Voiding cystometry showed that he had normal capacity stable bladder with leak at 200 ml and detrusor pressures in normal range []. On cystoscopy, the anastomotic site at posterior urethra at the junction of bulbar and prostatic urethra was identified and admitted 9F resectoscope with ease. The bladder mucosa was normal and the bladder neck was not closing adequately on withdrawal of the cystoscope into urethra.\nAfter detailed evaluation, he was put on conservative management for incontinence with a trial of anticholinergics, clean intermittent catheterization, pelvic floor exercises, and timed voiding for 6 weeks. The urinary leak persisted without any improvement. The child had suffered for 10 years and was constantly on diapers or using condom catheters with significant scarring of the penis and no relief with medical management.\nThe child was prepared for bulbar placement of the cuff by the perineal approach and placed in lithotomy position. A 12 F Foley catheter was placed. A midline perineal incision was made and bulbocavernosus muscle was dissected from the bulbar urethra by blunt dissection. Subdartos pouch was created through a separate inguinal incision for pump placement. The bulbar urethra was mobilized for cuff placement. We used the ZSI 375 (Zephyr surgical implants, Switzerland) artificial urinary sphincter []. The cuff was placed around the bulbar urethra with the urethral catheter in situ and secured with a nonabsorbable suture []. The urethral catheter was removed after filling the bladder and ZSI 375 was activated. The functioning of the sphincter device was checked and the position of the spring in the pump unit calibrated to the desired midline position. The pump was placed in subdartos pouch and fixed. The sphincter was deactivated and urethral catheter placed again.\nThe child was discharged the next day with the catheter in situ. Six weeks later, the catheter was removed and the device was activated. The father and the child were taught how to deflate the cuff. The child was observed for 24 hrs in the Hospital till he was comfortable in using the device. One year after surgery, the child now deflates the cuff on feeling the urge to micturate and passes urine in good stream, voids to completion with no incontinence.