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Artificial Urinary Sphincters
JUNE 1993, VOL 57, NO 6
AORN JOURNAL
Artificial Urinary Sphincters TREATMENT FOR POST-PROSTATECTOMY INCONTINENCE Debbie Tiemann, RN; Linda Shea, RN; Carl G. Klutke, MD; Kay Gaehle, RN; Shirley Moore, RN 'ormal urinary continence in men depends on accommodation of urine within the bladder at low pressure, functional closure of the bladder outlet, and the absence of inappropriate bladder contractions.' When the bladder has been exposed to insults (eg, long-standing outlet obstruction, radiation, chemotherapy, surgery), it can lose its compliance and fail to store urine. Urinary continence can be affected by bladder instability (ie, a bladder that contracts involuntarily), injury to the sphincter mechanisms (eg, stress incontinence), detrusor instability (ie.
Debbie Tiemann
Linda Shea
Debbie Tiemann, RN, BSN, is the urodynamic
nurse a t B a r n e s H o s p i t a l , W a s h i n g t o n University School of Medicine, St Louis. Sht. earned her bachelor of science degree in nui~sing f r o m the Medical University of South Carolina, Charleston. L i n d a S h e a , R N , B S N , i s head n u r s e .
Urological Surgerv Ditqision, Barnes Hospitul, 1366
uninhibited contractions), or poor bladder compliance. Incontinence that is bladder related can occur even when the sphincter and bladder outlet are normal. Patients with incontinence secondary to detrusor instability or poor bladder compliance generally require treatment aimed at the bladder (ie, bladder relaxant medication). In men, the bladder neck and proximal urethral sphincter mechanisms are responsible for closure of the bladder outlet (Fig 1). Both smooth and skeletal muscle contract to create pressure on the outlet. The external urethral sphincter consists of striated muscle that surrounds the urethra. This
Carl G. Klutke
Washington University School of Medicine, St Louis. She earned her bachelor of' science degree in nursing froni Wehster College. S t Louis. Carl G . Klutke, M D , is assistant professor of
urologic surgery at Barnes Hospital, Washington University Medical School, S t Louis.He earned his doctor cf medicine degree
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striated muscle supports and compresses the urethra and is concentrated in the area of the membranous urethra. When the distal sphincter mechanism is injured, stress incontinence (ie, leakage of urine when abdominal pressure increases) can occur. Surgery to remove the prostate gland results in the ablation of the bladder neck, leaving the distal sphincter mechanism primarily responsible for passive continence. In the past, injury to the distal urethral sphincter mechanism during prostatectomy was believed to be the most common cause of post-prostatectomy incontinence.2 A more recent report suggests that sphincter insufficiency alone is the cause of incontinence in a small population of patients.3
The Artijicial Sphincter
T
e artificial sphincter is a major breakthrough in treatment of male urinary incontinence. The indications for this device, however, are limited to patients whose major abnormality is sphincter insufficiency. Patients with bladder-related incontinence are not good candidates for this device, as incontinence
Kay Gaehle
at the University of Michigan, Ann Arbor.
Kay Gaehle, RN, MSN, is assistant professor of nursing at Barnes, College, St Louis. She earned her diploma in nursing from Deaconess Hospital, St Louis, her bachelor of science degree in nursing from Elmhurst (111) College, and her master of science degree in nursing from St Louis University.
persists due to the inability of the bladder to store urine properly. The artificial sphincter provides greater outlet pressure, but patients with detrusor instability or poorly compliant bladders override the outlet closing device and leakage persists. Furthermore, the combination of an artificial sphincter and a bladder that is unable to store urine at low pressures can cause reflux and hydronephrosis. This potential complication underscores the importance of thorough preoperative evaluation, with special attention to bladder function by the urodynamic study, in the management of post-prostatectomy incontinence.
Preoperative Evaluation
P
atient counseling is an essential component of the preoperative evaluation. The patient’s overall physical and mental status and his motivation must be assessed. The patient must be able to understand how the urinary sphincter device operates and know when a problem with the device has occurred. The patient also must have the physical ability to manipulate the pump and be willing to perform this necessary function three to four times a day.
Shirley Moore
Shirley Moore, RN, MS, MSN, is assistant professor of nursing at Barnes College, St Louis. She received her bachelor of science degree in nursing f r o m the University of Illinois, Chicago, her master of science degree in biology f r o m Illinois State University, Normal, and her master of science degree in nursing from Northern lllinois State University, Normal. 1367
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sphincter
urethra
scrotum
Fig I. Male urinary sphincter. (Figure courtesy qf Anieiicon Medical Svstenn, Minnetotika,Mitin)
The patient is counseled by the surgeon on how the artificial sphincter operates and the potential risks and complications that may occur. Potential complications include bleeding, infection, erosion of the cuff. malfunction of the device. anesthetic related complications. and the possible need to remove the device or replace one or more of the components. Patient education is enhanced by using an artificial sphincter. a videotape that describes the procedure and the function of the artificial sphincter, pamphlets, and assorted articles. The preoperative physical evaluation of the patient being considered for placement of an artificial sphincter has two goals: to confirm the presence of stress urinary incontinence and to identify any contraindications to surgery or adverse factors that require pharmacologic or surgical management before placement of the device. The evaluation generally includes urodynamic testing and cystoscopy. Urodynamic evaluation defines the underlying cause of the patient’s incontinence. The study identifies the presence of stress incontinence. bladder instability, or a mixed component of the 1368
two. This evaluation yields useful information regarding bladder capacity, compliance, and emptying ability. Ideally, the urodynamic study will demonstrate a near-normal capacity bladder (ie, approximately 400 mL) with good compliance, minimal post-void residuals, the presence of stress incontinence upon coughing and straining, and the absence of bladder instability. If bladder instability is identified, particularly high pressure instability, the patient will need to be treated initially with anticholinergic medication and bladder training exercises before placement of the artificial sphincter. Cystoscopy. Cystoscopy is performed to observe sphincter activity and to identify the presence of any obstruction. Cystoscopy is particularly important in males with contractures, strictures, or anastomotic obstructions following prostatectomy. Voiding cystourethrogram. This radiologic examination is helpful in patients in which the possibility of an anatomic abnormality of the bladder outlet is particularly high. Any identified obstruction will require surgical correction before placement of the artificial sphincter. Urodynamics procedure. Patients undergoing this procedure must have a negative urine culture to decrease the possibility of an ascending infection of the urinary tract. The urodynamics nurse takes the patient’s history prior to the procedure, focusing on the genitourinary, cardiac, and neurologic systems and past surgical history, and verifying the absence of glaucoma in the event the patient requires anticholinergic medication. The urodynamics protocol is described in Table 1 and Figures 2, 3, and 4. Patient privacy, comfort, and cooperation are paramount to obtain the most accurate, meaningful information from this procedure. The study generally is performed with the patient undressed from the waist down and draped in a sitting position in the procedure chair. If the patient’s mobility is limited, the study can be performed with the patient in the supine position on a stretcher. Laboratory evaluation, physica2 examination. When the surgeon and patient decide to proceed with surgery, the patient’s workup is
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Table 1
Urodynamics Procedure
P
atient privacy, comfort, and cooperation are paramount to obtain the most accurate, meaningful information from this procedure. 1. The nurse obtains the patient’s history and explains the procedure to the patient. 2. The patient empties his bladder into a container that rests on a load cell, which records the baseline noninvasive urine flow rate (ie, uroflowmetry). This screening test detects a reduced flow rate or abnormal flow pattern. 3. The patient disrobes and sits in the procedure chair in a reclining position. The nurse preps the genitals with povidone-iodine; places a urodynamic catheter (pediatric size 7), a rectal catheter, and electromyelogram (EMG) surface electrodes on the perineum. The urodynamic catheter, a double-lumen catheter, permits simultaneous bladder filling and measurement of bladder pressure. The rectal catheter measures abdominal pressure and permits accurate measurement of bladder pressure by distinguishing pressure increases caused by Valsalva maneuvers (ie, straining). The EMG surface electrodes measure gross muscle activity in the pelvic floor and help identify dyssynergia or discoordination between the bladder and sphincter during voiding. 4. The nurse measures the patient’s postvoid residual urine via the urodynamic catheter; less than 90 mL is considered normal. 5. The nurse connects both the urodynamic and rectal catheters to transducers. The urodynamic catheter also is connected to a normal saline filling solution. 6. The patient returns to a sitting position in the chair. The nurse calibrates the transducers and asks the patient to cough to ensure that the monitor is recording bladder pressure, rectal pressure, and external mus-
cle activity via the patch electrodes. 7. Saline solution is infused at 60 mL/min into the bladder via the urodynamic catheter, and bladder pressure is obtained during filling (ie, cystometrogram). 8. The nurse instructs the patient to hold as much of the solution as possible. Most adult bladders are filled to a volume of 500 mL. 9.The patient is instructed to indicate his first sensation of filling, first desire to void, and point of urgency. 10. The patient may be asked to cough, strain, stand, walk, or jump to attempt to reproduce leakage or bladder instability. 11. Filling of the bladder is discontinued if the patient complains of pain, when he indicates being at the point of urgency, or when the bladder has filled to 500 mL. The patient then empties his bladder and voids with the urodynamic catheter in place so that voiding pressure can be measured. The solution flows around the urodynamic catheter as the patient voids, and a flow rate is obtained at the same time (ie, pressure flow study). 12. The patient is placed in the lithotomy position for measurement of post-void residual urine. Residual amounts may be more than 90 mL due to various factors (eg, voiding with catheter in place, nurse in attendance). All tubes are removed. The patient returns to a sitting position, and the nurse gives him a warm towel to dry the perineum. 14. The urologist and nurse interpret the tracing for the following information: bladder capacity, compliance (ie, volume/pressure relationship during bladder filling), ability to empty, bladder instability (ie, involuntary contractions of the bladder during filling that may be associated with leakage), and stress incontinence. 15. The patient receives antibiotic coverage for two days after the procedure.
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Fig 2. Urodynamics monitor.
Frame 1 Frame 2 Frame 3 Frame 4 Frame 5
Fig 4. Urodynamic procedure tracing.
Fig 3. Urodynamics procedure chair. 1370
Top two frames show large spikes when patient coughed. Frame three shows normal bladder stability. Frame four shows leakage (ie, small spikes) only with cough. Frame five shows bladder volume. Curves at the end of frames three and four indicate patient voiding.
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completed by obtaining standard preoperative blood work (eg, electrolytes, hemoglobin, prothrombin time, partial thromboplastin time), urine culture, chest x-ray, and electrocardiogram. The urine culture must document the absence of infection. The preoperative physical examination must rule out the presence of scrotal or perineal cellulitis, which may be present due to urinary incontinence. Most patients scheduled for placement of an artificial sphincter are admitted the morning of their surgery and thus receive preoperative instructions in the urology office.
Surgical Procedure
S
urgeons implant the occlusive cuff of the artificial sphincter either in the bladder neck or the bulbous urethra. The decision about which site to use depends on the surgeon’s preference and the patient’s specific anatomic variables. The bulbous urethral implantation has the advantage of easier surgical dissection, especially after radical prostatectomy. If the cuff is to be placed around the bulbous urethra, the primary incision site is in the perineum. If the cuff is placed around the bladder neck, the primary incision site is the lower abdomen. The scrub nurse prepares the cuff in advance and removes all air within it (Fig 5). The nurse uses a solution consisting of a radiopaque iodine preparation and sterile water in a 5050 ratio. The radiopaque iodine preparation is used so that any postoperative mechanical problems can be visualized by performing an x-ray of the device.
Fig 5. Equipment used to prepare cuff.
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In the operating room, anesthesia personnel administer spinal or general anesthesia, and the surgical team places the patient in a modified lithotomy position. The circulating nurse shaves the patient and preps him with povidone-iodine solution from the umbilicus to the anus. Proper prepping of the patient is important to avoid infection of the prosthetic device. The surgeon drapes the patient so that the perineum and the lower quadrant of the abdomen are exposed. He or she inserts a Foley catheter into the patient’s urethra to drain the bladder and to facilitate locating the urethra by palpation. The surgeon makes a mid-line perineal incision that extends from the perineal scrota1junction to approximately one centimeter above the anal verge. Dissection in the subcutaneous tissue is carried out to expose the bulbocavernosus muscle. The surgeon separates and dissects this muscle free of the underlying bulbous urethra and exposes the bulbous urethra by blunt and sharp dissection. He or she continues this dissection laterally and circumferentially to completely free a 2-cm segment of the bulbous urethra from the surrounding tissue. Once this section of the urethra has been completely freed from the surrounding tissue, the surgeon removes the Foley catheter and places a cuffsizing device around the patient’s urethra to determine the proper diameter cuff to be used. Cuff sizes range from 4.5 cm to 6 cm; the 4.5 cm cuff is used most commonly. The surgeon takes care to avoid any injury to the urethra that subsequently could result in erosion of the cuff. The cuff is positioned around the bulbous urethra by passing it in a straight section and connecting the free ends, much like placing a piece of tape around a tube. The fit should be snug, but not tight. Throughout this procedure, air is kept out of the system by maintaining rubber shod clamps on the ends of all tubing sites. After the cuff is implanted, the surgeon can place the pressure-regulating balloon. The surgeon makes a 4-cm inguinal incision in the right or left lower abdomen depending on which side of the scrotum is used for the pump. Dissection is carried through the rectus fascia,
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and a small pocket, which will confine the pressure-regulating balloon, is created underneath the rectus muscle. Pressure-regulating balloons have various capacities (eg, 51 to 60 cm, 61 to 70 cm, 71 to 80 cm water pressure). Although the balloon eventually is filled with only 22 mL of fluid, the different capacities represent the force actually exerted (ie, centimeters of water pressure) on the sphincter cuff. In the bulbous urethral approach, the typical size pressure-regulating balloon used is 61 to 70 cm. Once the proper balloon has been determined by the surgeon, the scrub nurse prepares it by removing all air and attaching a syringe filled with the appropriate solution to the balloon. Using a metal passing device, the surgeon passes the tubing from the previously implanted cuff subcutaneously up into the abdominal incision. He or she places the balloon behind the patient’s rectus muscle, and the inguinal incision is reapproximated using 2-0 absorbable suture. The surgeon fills the balloon with 22 mL of the recommended contrast media-sterile water solution. The scrub nurse uses the recommended solution to purge the pump mechanism of all air. The surgeon makes a subcutaneous tunnel from the lower abdominal incision down to the scrotum using a ring clamp. The pump must be placed in the most dependent portion of the scrotum; therefore, this tunnel must extend to the very lowest aspect of the scrotum. The pump is passed down the subcutaneous tunnel into the base of the scrotum and held in place from outside by placing a Babcock clamp on the scrota1 skin surrounding the pump. The surgeon trims the tubes connecting the cuff, pump, and pressure-regulating balloon to the proper length. These tubes are identified by markings placed by the manufacturer. After flushing the ends of the tubing with sterile water, the surgeon connects the pump and the cuff and the pump and the balloon. A connecting device, which has the appearance of a wrench, and small plastic joints comprise the connections. The system (Fig 6 ) is tested to be sure that cycling of fluid occurs, that the system is deactivated by squeezing the control pump, and that it is deactivated by
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W Fig 6. Artificial sphincter system. (Figure courtesy of American Medical Systems, Minnetonka, Minn) pressing the deactivation button, located on the upper aspect of the control pump. Two incisions have been made: one in the perineum for placement of the cuff and one in the lower abdomen for placement of the pump and balloon and connection of the tubing. After careful and copious irrigation, the surgical team closes the wounds. A small-caliber Foley catheter (eg, 12 Fr) is left in place overnight. The system is not activated until six weeks following surgery to allow complete healing before beginning cuff compression of the urethra.
Postoperative Care
T
he patient remains in the hospital for two to three days. The nurses assess the patient for immediate postoperative complications (eg, infection, bleeding, urinary obstruction) and prepare the patient for self-care. Nursing assessments focus on adequacy of urinary output, spinal anesthesia recovery, breath sounds, vital signs/temperature, bowel function, condition of wounds, ambulation, and diet. Early patient discharge is dependent on preventing complications related to immobility. 1375
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Ambulation begins the evening of surgery if the patient is fully recovered from spinal anesthesia. The nurse encourages the patient to turn, cough, and deep breathe every two hours and to use an incentive spirometer hourly to prevent pulmonary stasis. If the patient has a history of cardiac disease or is unlikely to ambulate early during the postoperative period, he wears thigh-high antiembolism stockings, applied in the OR, to prevent thrombus formation in the lower extremities. The physician prescribes intravenous fluids and prophylactic gentamicin and cefazolin sodium (Ancef) until the patient tolerates oral intake. Once tolerating oral fluids, the patient receives cephalexin (Keflex) orally four times daily and is instructed by the nurse to drink 2,400 mL of fluid per day. The patient progresses to a regular diet based on the nursing assessment of gastrointestinal tolerance and function. The patient knows that following surgical implantation, the artificial sphincter will remain deactivated for a six-week time period. When the nurse removes the Foley catheter the day following surgery, the patient will remain incontinent for the next six weeks. Assessment of urinary output poses a challenge to the nurse if the patient has little or no control over micturition. Palpating the suprapubic area to detect a distended bladder and keeping a urinal in place while the patient is in bed may be necessary to assess adequacy of urinary output. The nurse must provide physical as well as emotional support to the patient during this transitional time. The nurse administers meperidine (Demerol) and hydroxyzine pamoate (Vistaril) to control postoperative pain. As the patient becomes more comfortable, propoxyphene napsylate (DarvosetN) serves as an appropriate analgesic substitute. A scrota1 support is applied in the OR and used postoperatively to provide additional comfort. At discharge, the patient is instructed to 0 force fluids (ie, 8 to 10 glasses per day), avoid strenuous activity such as lifting, return to the urologist for skin staple removal seven days following the operative procedure,
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Cuff filled with fluid gently squeezes urethra closed to keep urine in bladder.
To urinate, cuff is opened by squeezing pump. Fluid moves out of cuff into the balloon. Urine flows from the bladder.
After patient urinates, fluid automatically flows from balloon to the cuff. When cuff is full, it squeezes urethra closed. (Figures courtesy of American Medical Systems, Miiznetonka, ~ ~ n n ~ Fig 7 . Urinary sphincter activation. 1377
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Fig 8. Close-up view of assembled prosthesis.
take cephalexin (Keflex) 250 mg orally four times daily, take propoxyphene napsylate (DarvosetN) PRN for discomfort, and return to the urologist six weeks postoperatively for activation of the sphincter. Figure 7 shows the urinary sphincter activation procedure. Figure 8 illustrates the assembled prosthesis. Once the patient leams to activate the artificial sphincter and uses it to control micturition, it is imperative that he carry identification to notify health care personnel of the presence of the device. This is especially important should the patient be in an accident or be physically or mentally incapable of informing health professionals that he has an artificial urinary sphincter. Health professionals can then deactivate the sphincter and assess urinary output.
Case Studies
T
wo case studies illustrate the use of artificial urinary sphincters. Mr K is a 56year-old male who underwent a radical prostatectomy for prostatic cancer. Postoperatively, Mr K experienced urinary incontinence 1378
and impotence. Mr K’s incontinence was characterized by uncontrolled urination at any time; worsened urine leakage when standing, coughing, or straining; and soaking three to 12 sanitary pads with urine on a daily basis. Mr K did not have urinary hesitancy or urgency. Mr K was treated with collagen injections into the urethra in an attempt to control the incontinence, but no improvement of symptoms occurred. Urodynamic evaluation resulte d in a diagnosis of outlet dysfunction. Following consultation with a urologist, Mr K agreed to have an artificial sphincter inserted to control his micturition. After the urinary sphincter was inserted, Mr K’s postoperative course was uneventful. His Foley catheter was removed on the first postoperative day, and as predicted, Mr K continued to be incontinent. Cefazolin sodium (Ancef) and gentamicin were used prophylactically for 24 hours followed by oral cephalexin. Mr K was discharged four days after surgery with instructions to return for a follow-up exam in one week and again six weeks after discharge for activation of the artificial sphincter. Mr C is an 80-year-old male who previously had been diagnosed as having a urethral stricture and urethral sphincter incontinence. Following a transurethral resection of the prostate for benign prostatic hypertrophy, Mr C was totally incontinent. A urethral Teflon injection was performed to control the incontinence, but the symptoms did not improve. The goal of treatment with Teflon injections is to increase resistance to urine o ~ t f l o w . ~ Following an extensive diagnostic workup, Mr C underwent an optical internal urethrotomy of the stricture and placement of an artificial sphincter. Mr C’s postoperative course was uneventful except for chest pain, which was successfully treated with nitroglycerin, and hypertension, which responded to sublingual nifedipine (Procardia). Mr C was discharged on the fifth postoperative day. Six months following this procedure, Mr C required a revision of the artificial sphincter because the pressure-regulating balloon pressure was inadequate to maintain continence.
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The pressure was increased, and Mr C was discharged the following day without incident.
Summary
T
he artificial urinary sphincter offers patients who have incontinence due to loss of sphincter control the chance to regain control over urination. A well-planned diagnostic evaluation readily identifies patients who can benefit from this operative procedure. Placement of the artificial urinary sphincter is individualized to each patient’s anatomic structure. Through the combined efforts of the surgeon, the urodynamics nurse, the surgical team, and the postoperative nursing staff, these patients experience a quick recovery and rapid return of control over bladder function. 0 AORN recognizes this article as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Association Credentialing Center’s Commission on Accreditation approves or endorses any product included in the presentation. Professional nurses are invited to submit manuscripts f o r the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal, 21 7 0 S Parker R d , Suite 300, Denver, CO 80231-5711. As with all manuscripts sent to the Journal, papers submitted for home study programs should not be previously published or submitted simultaneously to any other publication.
Notes 1. S Raz, J J Kaufmann, “Urodynamics of post prostatectomy incontinence,”(Editorial) Urological
Research 4 (July 23, 1976) 447-448. 2. Ibid. 3. G E Leach, C M Yip, B J Donovan, “Postprostatectomy incontinence: The influence of bladder dysfunction,” Journal of Urology 138 (September 1987) 574-578. 4. P J Osther, H F Rohl, “Teflon injections in post-prostatectomy incontinence,” Scandinavian Journal of Urology and Nephrology 22 no 3 (1988) 171-174.
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Film Review
Skin Preparation of the Surgical Patient This 13-minute videotape includes a comprehensive study guide that provides a complete home study program for continuing education credits. This learning package details basic principles of perioperative skin preparation essential to successful surgical outcomes. Emphasis is placed on rationales behind and techniques of effective perioperative skin preparation. Antimicrobial skin preparation products and their ingredients are discussed. The author, Donna Wahoff-Stice, RN, MSN, CNOR, reviews the importance of documenting the preoperative skin assessment and preparation and the postoperative outcome. A thorough discussion of assessment of preoperative skin conditions is included in the study guide. Hair removal methods are discussed and demonstrated. Principles of prepping “clean to dirty” and the required mechanical actions are explained. This videotape is an excellent learning tool for the perioperative nursing student or novice and provides a good review for the experienced perioperative team member. The videotape is available in 1/2-inch VHS for $45 or 3/4-inch U-matic for $5 1. Rentals are available for $25. The home study guide is included. There is an additional $5 shipping and handling fee for all videotapes. Mail requests to Cine-Med Distribution Center, Davis+Geck Video Library, PO Box 745, Woodbury, CT 06798, or call (800) 633-0004. PATRICE SPERA,RN, CNOR AUDIOVISUAL COMMITTEE
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Examination ARTIFICIAL URINARY SPHINCTERS
1. Normal urinary continence in men depends on accommodation of urine in the bladder , functional closure of the at , and the absence of inappropriate bladder a. high pressurelmeatuslfunction b. low pressurebladder neckhpasms c. low pressurebladder outlet/contractions d. high pressure/bladder outlet/contractions
to be the most common cause of postprostatectomy a. infection b. incontinence c. urinary retention d. impotence 6. Patients with incontinence secondary to generally require treatment aimed at the bladder itself (such as, ).
2. The bladder neck and proximal urethral sphincter are responsible for mechanical closure of the bladder outlet. a. true b. false 3. The bladder can lose its compliance and fail to store urine when exposed to 1. long-standing outlet obstruction 2. chemotherapy, radiation 3. surgery 4. stress a. 1,3, and4 b. 2 a n d 3 c. 3 only d. 1 , 2 , a n d 3 4. When the is injured, stress incontinence can occur. a. urethra b. distal sphincter mechanism c. proximal sphincter mechanism d. trigone 5 . Prostatectomy can result in injury to the
distal sphincter mechanism and is thought
a. myelomeningocele/surgery b. detrusor instability/bladder relaxant medication c. bladder outlet obstruction/surgery d. detrusor instability/artificial urinary sphincters
7. Patients with bladder-related incontinence are good candidates for the artificial urinary sphincter (AUS). a. true b. false 8. In patients with detrusor instability or poorly compliant bladders, the closing device of the AUS can be overridden and can persist. a. infection b. leakage c. device erosion d. device failure 9. Use of the AUS is limited to patients whose major abnormality is a. sphincter insufficiency b. sphincter stenosis 1381
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c. compliant bladders d. detrusor instability
10. The combination of an AUS and a bladder that is unable to store urine at low pressures can cause and a. reflux/hydronephrosis b. retention/infection c. incontinence/retention d. impotence/infection 1 1. With a patient planning to undergo an AUS
procedure, the nurse should assess that the patient is able to 1. understand how the device works 2. store urine at low pressures 3. recognize a problem with the AUS when it develops 4. physically manipulate the device a. 1 and2 b. 2 and 4 c. 1,3, and4 d. 2 , 3 , a n d 4 12. An important part of the preoperative evaluation is the performance of a urodynamic evaluation. This includes a. cystoscopy. voiding cystourethrogram, and psychological evaluation b. cystoscopy, voiding cystourethrogram, and urodynamics procedure c. psychological evaluation and urodynamics procedure d. cystoscopy and urodynamics procedure
13. On the laboratory report, it is important for the nurse to note that a urine culture has been done and that the results are negative. a. true b. false 14. Meticulous prepping of the patient is needed to prevent the prosthetic device. a. damage to b. infection of c. improper handling of d. warranty cancellation of 1382
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15. The surgeon will make an inguinal and a midline perineal incision. The nurse preps the patient from the to the . a. sternumknees b. umbilicus/knees c. ribsfpubis d. umbilicus/anus
16. The scrub nurse must prepare the reservoir by removing all and attaching a syringe filled with the appropriate solution. a. solution b. air c. connections d. tubing
17. The AUS system should be tested to see that all fluid cycles appropriately before implantation. a. true b. false 18. The AUS system is not activated for weeks to allow complete healing before urethral compress ion occurs. a. two b. four c. six d. eight 19. Postoperative nursing care assessments focus on the patient’s a. pain control b. adequate urinary output c. preventing infection d. discharge 20. Postoperatively, the patient may require psychological support from the nurse. Why? a. After Foley catheter removal, the patient will be incontinent for six weeks until the sphincter is activated. b. The patient may be unwilling to void. c. The patient will not have the skill to work the AUS and be depressed. d. The patient may be impotent.
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Answer Sheet ARTIFICIAL URINARY SPHINCTERS
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lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Describe the etiology of male urinary incontinence. (2) Identify appropriate patients for the artificial urinary sphincter. ( 3 ) Discuss the role of the perioperative nurse.
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(High)
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2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives?
3. Test questionslanswers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
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AORN JOURNAL
Artificial Urinary Sphincters TREATMENT FOR POST-PROSTATECTOMY INCONTINENCE Debbie Tiemann, RN; Linda Shea, RN; Carl G. Klutke, MD; Kay Gaehle, RN; Shirley Moore, RN 'ormal urinary continence in men depends on accommodation of urine within the bladder at low pressure, functional closure of the bladder outlet, and the absence of inappropriate bladder contractions.' When the bladder has been exposed to insults (eg, long-standing outlet obstruction, radiation, chemotherapy, surgery), it can lose its compliance and fail to store urine. Urinary continence can be affected by bladder instability (ie, a bladder that contracts involuntarily), injury to the sphincter mechanisms (eg, stress incontinence), detrusor instability (ie.
Debbie Tiemann
Linda Shea
Debbie Tiemann, RN, BSN, is the urodynamic
nurse a t B a r n e s H o s p i t a l , W a s h i n g t o n University School of Medicine, St Louis. Sht. earned her bachelor of science degree in nui~sing f r o m the Medical University of South Carolina, Charleston. L i n d a S h e a , R N , B S N , i s head n u r s e .
Urological Surgerv Ditqision, Barnes Hospitul, 1366
uninhibited contractions), or poor bladder compliance. Incontinence that is bladder related can occur even when the sphincter and bladder outlet are normal. Patients with incontinence secondary to detrusor instability or poor bladder compliance generally require treatment aimed at the bladder (ie, bladder relaxant medication). In men, the bladder neck and proximal urethral sphincter mechanisms are responsible for closure of the bladder outlet (Fig 1). Both smooth and skeletal muscle contract to create pressure on the outlet. The external urethral sphincter consists of striated muscle that surrounds the urethra. This
Carl G. Klutke
Washington University School of Medicine, St Louis. She earned her bachelor of' science degree in nursing froni Wehster College. S t Louis. Carl G . Klutke, M D , is assistant professor of
urologic surgery at Barnes Hospital, Washington University Medical School, S t Louis.He earned his doctor cf medicine degree
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striated muscle supports and compresses the urethra and is concentrated in the area of the membranous urethra. When the distal sphincter mechanism is injured, stress incontinence (ie, leakage of urine when abdominal pressure increases) can occur. Surgery to remove the prostate gland results in the ablation of the bladder neck, leaving the distal sphincter mechanism primarily responsible for passive continence. In the past, injury to the distal urethral sphincter mechanism during prostatectomy was believed to be the most common cause of post-prostatectomy incontinence.2 A more recent report suggests that sphincter insufficiency alone is the cause of incontinence in a small population of patients.3
The Artijicial Sphincter
T
e artificial sphincter is a major breakthrough in treatment of male urinary incontinence. The indications for this device, however, are limited to patients whose major abnormality is sphincter insufficiency. Patients with bladder-related incontinence are not good candidates for this device, as incontinence
Kay Gaehle
at the University of Michigan, Ann Arbor.
Kay Gaehle, RN, MSN, is assistant professor of nursing at Barnes, College, St Louis. She earned her diploma in nursing from Deaconess Hospital, St Louis, her bachelor of science degree in nursing from Elmhurst (111) College, and her master of science degree in nursing from St Louis University.
persists due to the inability of the bladder to store urine properly. The artificial sphincter provides greater outlet pressure, but patients with detrusor instability or poorly compliant bladders override the outlet closing device and leakage persists. Furthermore, the combination of an artificial sphincter and a bladder that is unable to store urine at low pressures can cause reflux and hydronephrosis. This potential complication underscores the importance of thorough preoperative evaluation, with special attention to bladder function by the urodynamic study, in the management of post-prostatectomy incontinence.
Preoperative Evaluation
P
atient counseling is an essential component of the preoperative evaluation. The patient’s overall physical and mental status and his motivation must be assessed. The patient must be able to understand how the urinary sphincter device operates and know when a problem with the device has occurred. The patient also must have the physical ability to manipulate the pump and be willing to perform this necessary function three to four times a day.
Shirley Moore
Shirley Moore, RN, MS, MSN, is assistant professor of nursing at Barnes College, St Louis. She received her bachelor of science degree in nursing f r o m the University of Illinois, Chicago, her master of science degree in biology f r o m Illinois State University, Normal, and her master of science degree in nursing from Northern lllinois State University, Normal. 1367
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sphincter
urethra
scrotum
Fig I. Male urinary sphincter. (Figure courtesy qf Anieiicon Medical Svstenn, Minnetotika,Mitin)
The patient is counseled by the surgeon on how the artificial sphincter operates and the potential risks and complications that may occur. Potential complications include bleeding, infection, erosion of the cuff. malfunction of the device. anesthetic related complications. and the possible need to remove the device or replace one or more of the components. Patient education is enhanced by using an artificial sphincter. a videotape that describes the procedure and the function of the artificial sphincter, pamphlets, and assorted articles. The preoperative physical evaluation of the patient being considered for placement of an artificial sphincter has two goals: to confirm the presence of stress urinary incontinence and to identify any contraindications to surgery or adverse factors that require pharmacologic or surgical management before placement of the device. The evaluation generally includes urodynamic testing and cystoscopy. Urodynamic evaluation defines the underlying cause of the patient’s incontinence. The study identifies the presence of stress incontinence. bladder instability, or a mixed component of the 1368
two. This evaluation yields useful information regarding bladder capacity, compliance, and emptying ability. Ideally, the urodynamic study will demonstrate a near-normal capacity bladder (ie, approximately 400 mL) with good compliance, minimal post-void residuals, the presence of stress incontinence upon coughing and straining, and the absence of bladder instability. If bladder instability is identified, particularly high pressure instability, the patient will need to be treated initially with anticholinergic medication and bladder training exercises before placement of the artificial sphincter. Cystoscopy. Cystoscopy is performed to observe sphincter activity and to identify the presence of any obstruction. Cystoscopy is particularly important in males with contractures, strictures, or anastomotic obstructions following prostatectomy. Voiding cystourethrogram. This radiologic examination is helpful in patients in which the possibility of an anatomic abnormality of the bladder outlet is particularly high. Any identified obstruction will require surgical correction before placement of the artificial sphincter. Urodynamics procedure. Patients undergoing this procedure must have a negative urine culture to decrease the possibility of an ascending infection of the urinary tract. The urodynamics nurse takes the patient’s history prior to the procedure, focusing on the genitourinary, cardiac, and neurologic systems and past surgical history, and verifying the absence of glaucoma in the event the patient requires anticholinergic medication. The urodynamics protocol is described in Table 1 and Figures 2, 3, and 4. Patient privacy, comfort, and cooperation are paramount to obtain the most accurate, meaningful information from this procedure. The study generally is performed with the patient undressed from the waist down and draped in a sitting position in the procedure chair. If the patient’s mobility is limited, the study can be performed with the patient in the supine position on a stretcher. Laboratory evaluation, physica2 examination. When the surgeon and patient decide to proceed with surgery, the patient’s workup is
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Table 1
Urodynamics Procedure
P
atient privacy, comfort, and cooperation are paramount to obtain the most accurate, meaningful information from this procedure. 1. The nurse obtains the patient’s history and explains the procedure to the patient. 2. The patient empties his bladder into a container that rests on a load cell, which records the baseline noninvasive urine flow rate (ie, uroflowmetry). This screening test detects a reduced flow rate or abnormal flow pattern. 3. The patient disrobes and sits in the procedure chair in a reclining position. The nurse preps the genitals with povidone-iodine; places a urodynamic catheter (pediatric size 7), a rectal catheter, and electromyelogram (EMG) surface electrodes on the perineum. The urodynamic catheter, a double-lumen catheter, permits simultaneous bladder filling and measurement of bladder pressure. The rectal catheter measures abdominal pressure and permits accurate measurement of bladder pressure by distinguishing pressure increases caused by Valsalva maneuvers (ie, straining). The EMG surface electrodes measure gross muscle activity in the pelvic floor and help identify dyssynergia or discoordination between the bladder and sphincter during voiding. 4. The nurse measures the patient’s postvoid residual urine via the urodynamic catheter; less than 90 mL is considered normal. 5. The nurse connects both the urodynamic and rectal catheters to transducers. The urodynamic catheter also is connected to a normal saline filling solution. 6. The patient returns to a sitting position in the chair. The nurse calibrates the transducers and asks the patient to cough to ensure that the monitor is recording bladder pressure, rectal pressure, and external mus-
cle activity via the patch electrodes. 7. Saline solution is infused at 60 mL/min into the bladder via the urodynamic catheter, and bladder pressure is obtained during filling (ie, cystometrogram). 8. The nurse instructs the patient to hold as much of the solution as possible. Most adult bladders are filled to a volume of 500 mL. 9.The patient is instructed to indicate his first sensation of filling, first desire to void, and point of urgency. 10. The patient may be asked to cough, strain, stand, walk, or jump to attempt to reproduce leakage or bladder instability. 11. Filling of the bladder is discontinued if the patient complains of pain, when he indicates being at the point of urgency, or when the bladder has filled to 500 mL. The patient then empties his bladder and voids with the urodynamic catheter in place so that voiding pressure can be measured. The solution flows around the urodynamic catheter as the patient voids, and a flow rate is obtained at the same time (ie, pressure flow study). 12. The patient is placed in the lithotomy position for measurement of post-void residual urine. Residual amounts may be more than 90 mL due to various factors (eg, voiding with catheter in place, nurse in attendance). All tubes are removed. The patient returns to a sitting position, and the nurse gives him a warm towel to dry the perineum. 14. The urologist and nurse interpret the tracing for the following information: bladder capacity, compliance (ie, volume/pressure relationship during bladder filling), ability to empty, bladder instability (ie, involuntary contractions of the bladder during filling that may be associated with leakage), and stress incontinence. 15. The patient receives antibiotic coverage for two days after the procedure.
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Fig 2. Urodynamics monitor.
Frame 1 Frame 2 Frame 3 Frame 4 Frame 5
Fig 4. Urodynamic procedure tracing.
Fig 3. Urodynamics procedure chair. 1370
Top two frames show large spikes when patient coughed. Frame three shows normal bladder stability. Frame four shows leakage (ie, small spikes) only with cough. Frame five shows bladder volume. Curves at the end of frames three and four indicate patient voiding.
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completed by obtaining standard preoperative blood work (eg, electrolytes, hemoglobin, prothrombin time, partial thromboplastin time), urine culture, chest x-ray, and electrocardiogram. The urine culture must document the absence of infection. The preoperative physical examination must rule out the presence of scrotal or perineal cellulitis, which may be present due to urinary incontinence. Most patients scheduled for placement of an artificial sphincter are admitted the morning of their surgery and thus receive preoperative instructions in the urology office.
Surgical Procedure
S
urgeons implant the occlusive cuff of the artificial sphincter either in the bladder neck or the bulbous urethra. The decision about which site to use depends on the surgeon’s preference and the patient’s specific anatomic variables. The bulbous urethral implantation has the advantage of easier surgical dissection, especially after radical prostatectomy. If the cuff is to be placed around the bulbous urethra, the primary incision site is in the perineum. If the cuff is placed around the bladder neck, the primary incision site is the lower abdomen. The scrub nurse prepares the cuff in advance and removes all air within it (Fig 5). The nurse uses a solution consisting of a radiopaque iodine preparation and sterile water in a 5050 ratio. The radiopaque iodine preparation is used so that any postoperative mechanical problems can be visualized by performing an x-ray of the device.
Fig 5. Equipment used to prepare cuff.
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In the operating room, anesthesia personnel administer spinal or general anesthesia, and the surgical team places the patient in a modified lithotomy position. The circulating nurse shaves the patient and preps him with povidone-iodine solution from the umbilicus to the anus. Proper prepping of the patient is important to avoid infection of the prosthetic device. The surgeon drapes the patient so that the perineum and the lower quadrant of the abdomen are exposed. He or she inserts a Foley catheter into the patient’s urethra to drain the bladder and to facilitate locating the urethra by palpation. The surgeon makes a mid-line perineal incision that extends from the perineal scrota1junction to approximately one centimeter above the anal verge. Dissection in the subcutaneous tissue is carried out to expose the bulbocavernosus muscle. The surgeon separates and dissects this muscle free of the underlying bulbous urethra and exposes the bulbous urethra by blunt and sharp dissection. He or she continues this dissection laterally and circumferentially to completely free a 2-cm segment of the bulbous urethra from the surrounding tissue. Once this section of the urethra has been completely freed from the surrounding tissue, the surgeon removes the Foley catheter and places a cuffsizing device around the patient’s urethra to determine the proper diameter cuff to be used. Cuff sizes range from 4.5 cm to 6 cm; the 4.5 cm cuff is used most commonly. The surgeon takes care to avoid any injury to the urethra that subsequently could result in erosion of the cuff. The cuff is positioned around the bulbous urethra by passing it in a straight section and connecting the free ends, much like placing a piece of tape around a tube. The fit should be snug, but not tight. Throughout this procedure, air is kept out of the system by maintaining rubber shod clamps on the ends of all tubing sites. After the cuff is implanted, the surgeon can place the pressure-regulating balloon. The surgeon makes a 4-cm inguinal incision in the right or left lower abdomen depending on which side of the scrotum is used for the pump. Dissection is carried through the rectus fascia,
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and a small pocket, which will confine the pressure-regulating balloon, is created underneath the rectus muscle. Pressure-regulating balloons have various capacities (eg, 51 to 60 cm, 61 to 70 cm, 71 to 80 cm water pressure). Although the balloon eventually is filled with only 22 mL of fluid, the different capacities represent the force actually exerted (ie, centimeters of water pressure) on the sphincter cuff. In the bulbous urethral approach, the typical size pressure-regulating balloon used is 61 to 70 cm. Once the proper balloon has been determined by the surgeon, the scrub nurse prepares it by removing all air and attaching a syringe filled with the appropriate solution to the balloon. Using a metal passing device, the surgeon passes the tubing from the previously implanted cuff subcutaneously up into the abdominal incision. He or she places the balloon behind the patient’s rectus muscle, and the inguinal incision is reapproximated using 2-0 absorbable suture. The surgeon fills the balloon with 22 mL of the recommended contrast media-sterile water solution. The scrub nurse uses the recommended solution to purge the pump mechanism of all air. The surgeon makes a subcutaneous tunnel from the lower abdominal incision down to the scrotum using a ring clamp. The pump must be placed in the most dependent portion of the scrotum; therefore, this tunnel must extend to the very lowest aspect of the scrotum. The pump is passed down the subcutaneous tunnel into the base of the scrotum and held in place from outside by placing a Babcock clamp on the scrota1 skin surrounding the pump. The surgeon trims the tubes connecting the cuff, pump, and pressure-regulating balloon to the proper length. These tubes are identified by markings placed by the manufacturer. After flushing the ends of the tubing with sterile water, the surgeon connects the pump and the cuff and the pump and the balloon. A connecting device, which has the appearance of a wrench, and small plastic joints comprise the connections. The system (Fig 6 ) is tested to be sure that cycling of fluid occurs, that the system is deactivated by squeezing the control pump, and that it is deactivated by
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J
W Fig 6. Artificial sphincter system. (Figure courtesy of American Medical Systems, Minnetonka, Minn) pressing the deactivation button, located on the upper aspect of the control pump. Two incisions have been made: one in the perineum for placement of the cuff and one in the lower abdomen for placement of the pump and balloon and connection of the tubing. After careful and copious irrigation, the surgical team closes the wounds. A small-caliber Foley catheter (eg, 12 Fr) is left in place overnight. The system is not activated until six weeks following surgery to allow complete healing before beginning cuff compression of the urethra.
Postoperative Care
T
he patient remains in the hospital for two to three days. The nurses assess the patient for immediate postoperative complications (eg, infection, bleeding, urinary obstruction) and prepare the patient for self-care. Nursing assessments focus on adequacy of urinary output, spinal anesthesia recovery, breath sounds, vital signs/temperature, bowel function, condition of wounds, ambulation, and diet. Early patient discharge is dependent on preventing complications related to immobility. 1375
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Ambulation begins the evening of surgery if the patient is fully recovered from spinal anesthesia. The nurse encourages the patient to turn, cough, and deep breathe every two hours and to use an incentive spirometer hourly to prevent pulmonary stasis. If the patient has a history of cardiac disease or is unlikely to ambulate early during the postoperative period, he wears thigh-high antiembolism stockings, applied in the OR, to prevent thrombus formation in the lower extremities. The physician prescribes intravenous fluids and prophylactic gentamicin and cefazolin sodium (Ancef) until the patient tolerates oral intake. Once tolerating oral fluids, the patient receives cephalexin (Keflex) orally four times daily and is instructed by the nurse to drink 2,400 mL of fluid per day. The patient progresses to a regular diet based on the nursing assessment of gastrointestinal tolerance and function. The patient knows that following surgical implantation, the artificial sphincter will remain deactivated for a six-week time period. When the nurse removes the Foley catheter the day following surgery, the patient will remain incontinent for the next six weeks. Assessment of urinary output poses a challenge to the nurse if the patient has little or no control over micturition. Palpating the suprapubic area to detect a distended bladder and keeping a urinal in place while the patient is in bed may be necessary to assess adequacy of urinary output. The nurse must provide physical as well as emotional support to the patient during this transitional time. The nurse administers meperidine (Demerol) and hydroxyzine pamoate (Vistaril) to control postoperative pain. As the patient becomes more comfortable, propoxyphene napsylate (DarvosetN) serves as an appropriate analgesic substitute. A scrota1 support is applied in the OR and used postoperatively to provide additional comfort. At discharge, the patient is instructed to 0 force fluids (ie, 8 to 10 glasses per day), avoid strenuous activity such as lifting, return to the urologist for skin staple removal seven days following the operative procedure,
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Cuff filled with fluid gently squeezes urethra closed to keep urine in bladder.
To urinate, cuff is opened by squeezing pump. Fluid moves out of cuff into the balloon. Urine flows from the bladder.
After patient urinates, fluid automatically flows from balloon to the cuff. When cuff is full, it squeezes urethra closed. (Figures courtesy of American Medical Systems, Miiznetonka, ~ ~ n n ~ Fig 7 . Urinary sphincter activation. 1377
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Fig 8. Close-up view of assembled prosthesis.
take cephalexin (Keflex) 250 mg orally four times daily, take propoxyphene napsylate (DarvosetN) PRN for discomfort, and return to the urologist six weeks postoperatively for activation of the sphincter. Figure 7 shows the urinary sphincter activation procedure. Figure 8 illustrates the assembled prosthesis. Once the patient leams to activate the artificial sphincter and uses it to control micturition, it is imperative that he carry identification to notify health care personnel of the presence of the device. This is especially important should the patient be in an accident or be physically or mentally incapable of informing health professionals that he has an artificial urinary sphincter. Health professionals can then deactivate the sphincter and assess urinary output.
Case Studies
T
wo case studies illustrate the use of artificial urinary sphincters. Mr K is a 56year-old male who underwent a radical prostatectomy for prostatic cancer. Postoperatively, Mr K experienced urinary incontinence 1378
and impotence. Mr K’s incontinence was characterized by uncontrolled urination at any time; worsened urine leakage when standing, coughing, or straining; and soaking three to 12 sanitary pads with urine on a daily basis. Mr K did not have urinary hesitancy or urgency. Mr K was treated with collagen injections into the urethra in an attempt to control the incontinence, but no improvement of symptoms occurred. Urodynamic evaluation resulte d in a diagnosis of outlet dysfunction. Following consultation with a urologist, Mr K agreed to have an artificial sphincter inserted to control his micturition. After the urinary sphincter was inserted, Mr K’s postoperative course was uneventful. His Foley catheter was removed on the first postoperative day, and as predicted, Mr K continued to be incontinent. Cefazolin sodium (Ancef) and gentamicin were used prophylactically for 24 hours followed by oral cephalexin. Mr K was discharged four days after surgery with instructions to return for a follow-up exam in one week and again six weeks after discharge for activation of the artificial sphincter. Mr C is an 80-year-old male who previously had been diagnosed as having a urethral stricture and urethral sphincter incontinence. Following a transurethral resection of the prostate for benign prostatic hypertrophy, Mr C was totally incontinent. A urethral Teflon injection was performed to control the incontinence, but the symptoms did not improve. The goal of treatment with Teflon injections is to increase resistance to urine o ~ t f l o w . ~ Following an extensive diagnostic workup, Mr C underwent an optical internal urethrotomy of the stricture and placement of an artificial sphincter. Mr C’s postoperative course was uneventful except for chest pain, which was successfully treated with nitroglycerin, and hypertension, which responded to sublingual nifedipine (Procardia). Mr C was discharged on the fifth postoperative day. Six months following this procedure, Mr C required a revision of the artificial sphincter because the pressure-regulating balloon pressure was inadequate to maintain continence.
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The pressure was increased, and Mr C was discharged the following day without incident.
Summary
T
he artificial urinary sphincter offers patients who have incontinence due to loss of sphincter control the chance to regain control over urination. A well-planned diagnostic evaluation readily identifies patients who can benefit from this operative procedure. Placement of the artificial urinary sphincter is individualized to each patient’s anatomic structure. Through the combined efforts of the surgeon, the urodynamics nurse, the surgical team, and the postoperative nursing staff, these patients experience a quick recovery and rapid return of control over bladder function. 0 AORN recognizes this article as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Association Credentialing Center’s Commission on Accreditation approves or endorses any product included in the presentation. Professional nurses are invited to submit manuscripts f o r the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal, 21 7 0 S Parker R d , Suite 300, Denver, CO 80231-5711. As with all manuscripts sent to the Journal, papers submitted for home study programs should not be previously published or submitted simultaneously to any other publication.
Notes 1. S Raz, J J Kaufmann, “Urodynamics of post prostatectomy incontinence,”(Editorial) Urological
Research 4 (July 23, 1976) 447-448. 2. Ibid. 3. G E Leach, C M Yip, B J Donovan, “Postprostatectomy incontinence: The influence of bladder dysfunction,” Journal of Urology 138 (September 1987) 574-578. 4. P J Osther, H F Rohl, “Teflon injections in post-prostatectomy incontinence,” Scandinavian Journal of Urology and Nephrology 22 no 3 (1988) 171-174.
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Film Review
Skin Preparation of the Surgical Patient This 13-minute videotape includes a comprehensive study guide that provides a complete home study program for continuing education credits. This learning package details basic principles of perioperative skin preparation essential to successful surgical outcomes. Emphasis is placed on rationales behind and techniques of effective perioperative skin preparation. Antimicrobial skin preparation products and their ingredients are discussed. The author, Donna Wahoff-Stice, RN, MSN, CNOR, reviews the importance of documenting the preoperative skin assessment and preparation and the postoperative outcome. A thorough discussion of assessment of preoperative skin conditions is included in the study guide. Hair removal methods are discussed and demonstrated. Principles of prepping “clean to dirty” and the required mechanical actions are explained. This videotape is an excellent learning tool for the perioperative nursing student or novice and provides a good review for the experienced perioperative team member. The videotape is available in 1/2-inch VHS for $45 or 3/4-inch U-matic for $5 1. Rentals are available for $25. The home study guide is included. There is an additional $5 shipping and handling fee for all videotapes. Mail requests to Cine-Med Distribution Center, Davis+Geck Video Library, PO Box 745, Woodbury, CT 06798, or call (800) 633-0004. PATRICE SPERA,RN, CNOR AUDIOVISUAL COMMITTEE
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Examination ARTIFICIAL URINARY SPHINCTERS
1. Normal urinary continence in men depends on accommodation of urine in the bladder , functional closure of the at , and the absence of inappropriate bladder a. high pressurelmeatuslfunction b. low pressurebladder neckhpasms c. low pressurebladder outlet/contractions d. high pressure/bladder outlet/contractions
to be the most common cause of postprostatectomy a. infection b. incontinence c. urinary retention d. impotence 6. Patients with incontinence secondary to generally require treatment aimed at the bladder itself (such as, ).
2. The bladder neck and proximal urethral sphincter are responsible for mechanical closure of the bladder outlet. a. true b. false 3. The bladder can lose its compliance and fail to store urine when exposed to 1. long-standing outlet obstruction 2. chemotherapy, radiation 3. surgery 4. stress a. 1,3, and4 b. 2 a n d 3 c. 3 only d. 1 , 2 , a n d 3 4. When the is injured, stress incontinence can occur. a. urethra b. distal sphincter mechanism c. proximal sphincter mechanism d. trigone 5 . Prostatectomy can result in injury to the
distal sphincter mechanism and is thought
a. myelomeningocele/surgery b. detrusor instability/bladder relaxant medication c. bladder outlet obstruction/surgery d. detrusor instability/artificial urinary sphincters
7. Patients with bladder-related incontinence are good candidates for the artificial urinary sphincter (AUS). a. true b. false 8. In patients with detrusor instability or poorly compliant bladders, the closing device of the AUS can be overridden and can persist. a. infection b. leakage c. device erosion d. device failure 9. Use of the AUS is limited to patients whose major abnormality is a. sphincter insufficiency b. sphincter stenosis 1381
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c. compliant bladders d. detrusor instability
10. The combination of an AUS and a bladder that is unable to store urine at low pressures can cause and a. reflux/hydronephrosis b. retention/infection c. incontinence/retention d. impotence/infection 1 1. With a patient planning to undergo an AUS
procedure, the nurse should assess that the patient is able to 1. understand how the device works 2. store urine at low pressures 3. recognize a problem with the AUS when it develops 4. physically manipulate the device a. 1 and2 b. 2 and 4 c. 1,3, and4 d. 2 , 3 , a n d 4 12. An important part of the preoperative evaluation is the performance of a urodynamic evaluation. This includes a. cystoscopy. voiding cystourethrogram, and psychological evaluation b. cystoscopy, voiding cystourethrogram, and urodynamics procedure c. psychological evaluation and urodynamics procedure d. cystoscopy and urodynamics procedure
13. On the laboratory report, it is important for the nurse to note that a urine culture has been done and that the results are negative. a. true b. false 14. Meticulous prepping of the patient is needed to prevent the prosthetic device. a. damage to b. infection of c. improper handling of d. warranty cancellation of 1382
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15. The surgeon will make an inguinal and a midline perineal incision. The nurse preps the patient from the to the . a. sternumknees b. umbilicus/knees c. ribsfpubis d. umbilicus/anus
16. The scrub nurse must prepare the reservoir by removing all and attaching a syringe filled with the appropriate solution. a. solution b. air c. connections d. tubing
17. The AUS system should be tested to see that all fluid cycles appropriately before implantation. a. true b. false 18. The AUS system is not activated for weeks to allow complete healing before urethral compress ion occurs. a. two b. four c. six d. eight 19. Postoperative nursing care assessments focus on the patient’s a. pain control b. adequate urinary output c. preventing infection d. discharge 20. Postoperatively, the patient may require psychological support from the nurse. Why? a. After Foley catheter removal, the patient will be incontinent for six weeks until the sphincter is activated. b. The patient may be unwilling to void. c. The patient will not have the skill to work the AUS and be depressed. d. The patient may be impotent.
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Answer Sheet ARTIFICIAL URINARY SPHINCTERS
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lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
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Program offered June 1993 The deadline for this program is Nov 30, 1993. 1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Describe the etiology of male urinary incontinence. (2) Identify appropriate patients for the artificial urinary sphincter. ( 3 ) Discuss the role of the perioperative nurse.
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2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives?
3. Test questionslanswers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
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