How is Urine Discharged from the Body?
The urine that is generated by the kidneys is stored in the bladder (urine bag). The brain is stimulated when it reaches a certain level and it is discharged via the urinary channel called the urethra. There are two pcs urine-retaining mechanisms in the urinary channel which we call the sphincters. The first sphincter at the bladder outlet is controlled automatically. Meaning that it is involuntary. The body itself retains the urine. This sphincter closes automatically after the urine is discharged. The lower sphincter however, is voluntary and allows us to retain urine whenever we want. Meaning that one of these mechanisms is involuntary and closes by itself and the other is voluntary, which we can open and close.
The urine continuously leaks when both these two bolts malfunction. Urine control can be achieved in cases only one sphincter is functional. Situations where both the automatic and voluntary mechanisms are damaged and therefore malfunction have social, hygienic and psychological impacts on the patient. In this case, the solution for urinary incontinence is artificial sphincter surgery.
What is Artificial Sphincter? (Urine Retaining Mechanism)
Artificial sphincter is an artificial mechanism that allows the patient to keep his urine under control. The dictionary meaning of sphincter is “a ring of muscle that surrounds an opening in the body and can contract to close it, for example for purpose of urine retention”. AMS 800 (American Medical System) is the most advanced artificial sphincter. There is only one Manufacturer Company in the world.
The artificial sphincter consists of 3 parts: the sphincter reservoir, a ring placed on the urinary channel (cuff) and a pump that allows the patient to easily control opening and closing. For urinating, the patient squeezes and releases the pump inside his scrotum. The water inside the sphincter ring that compresses and closes the urinary channel, returns to the sphincter reservoir. This relaxes and opens the urinary channel. The patient urinates. Later, the patient closes the urinary channel by pressing the pump again. The diameter of the ring to be placed on the urinary channel is calculated by a special measurement tool. The system operates according to the hydraulic mechanics principle.
In Which Cases is Artificial Sphincter Surgery Performed?
Artificial Sphincter surgery is mainly performed in cases here the bladder nerves are damaged (neurogenic bladder). In neurogenic bladder, the storage, discharge and urine retention functions of the bladder have been damaged.
It is used for all urinary incontinence that owe to injuries in the urinary channel.
Another reason of use is the full urinary incontinence that occurs after prostate surgeries. Both sphincters may be damaged during surgeries of the prostate owing to cancer or other simple reasons. The patient may not retain his urine and continuously leaks it.
It is also used in urinary incontinence, which occurs due to ruptures in the urinary channel associated with pelvis bone fractures. Both voluntary and involuntary sphincters are fully damaged in case of surgeries on the bladder, accidents inside and outside vehicles, open and closed surgeries, and ruptures in the rear urinary channel that is associated with pelvis bone fractures.
The majority of urinary incontinence in men and women can be treated by some drugs and different surgical techniques. Artificial sphincter surgery should only performed in cases where other treatments have failed and the patient continually leaks urine. If the urethra (urinary channel) has been damaged and a partial/complete stricture exists therein, the stricture in the urethra should be corrected with surgery. Artificial sphincter surgery can be performed after the urethra is repaired.
Prior to Artificial Sphincter Surgery
The patient is explained that he can use the artificial sphincter only after 4-8 weeks after its installation. During this time, the artificial sphincter adapts to the location where it is installed and creates a nest for itself.
As it is a synthetic material, artificial sphincter is prone to inflammation. For this reason, it is very important to keep the surgery are clean. The patient is prescribed some special solutions and antibiotics prior to surgery. The genital region hosts the maximum amount of microbes. Shaving the genital zone should personally be performed by the doctor that will perform the surgery.
Artificial sphincter Surgery
One may perform artificial sphincter surgery with several incisions: incision from the perineum (perineal incision) and incision from the location where the penis and the testis sac coalesce (Penoscrotal incision). We prefer penoscrotal incision (the location where the penis and the testis sac coalesce). And in women, we use a 5-6 cm horizontal incision from the lower abdomen above the pubis bone. Our technique doesn’t require a second incision as opposed to the perineal one. The procedure is performed by a single incision and no scar is left.
A catheter is placed in the urinary channel prior to surgery. The bulbar urethra region is reached, which is the widest and most fleshy section of the urinary channel. 2 cm portion of it is freed. A measurement strip is placed around it in a way not to squeeze the urethra. This allows the determination of the ideal urinary channel diameter and the artificial urethra ring is determined according to this measurement. Later, the artificial sphincter ring is placed. The artificial sphincter should be neither too tight nor too loose. The sphincter reservoir is placed next to the bladder. A nest created in the scrotum for the sphincter pump. Connection tubes are placed inside the scrotum. This procedure requires strict precision and rigor. One should pay extreme attention to hygiene for preventing the risk of infection. After the artificial sphincter is placed, it is tested for 3-4 times for verifying the correct functioning of its connections and mechanisms. The patient is asked not to inflate the sphincter with pump for 4-8 weeks. During this period, we wait for rehabilitation and the adaption of the ring to urinary channel. The patient is examined 2 weeks later. The system is operated after 6-8 weeks. For using the artificial sphincter, it is sufficient to strongly squeeze the pump that is placed inside the scrotum. We have the patient to repeat this simple procedure a few times and the patient is taught to use this mechanism.